Introduction

Surgical resection as well as total hepatectomy and livertransplantation have failed to produce favorable resultsin the treatment of hilar cholangiocarcinoma over thelong term. Even after formally curative resections, lo-coregional tumor recurrences developed in a high per-centage within the resection line and in regional lymphnodes [6]. In contrast, distant metastases have been de-scribed in most patients who exhibit a locoregional re-currence, but were the site of first failure in only 24%.Total hepatectomy and liver transplantation did notsubstantially improve survival figures, partly due to aconsiderable rate of recurrence at the pancreatic head[1±3, 8, 12]. In 1992, we proposed the �extended bileduct resection', a procedure combining total hepatect-omy, partial pancreatoduodenectomy, and liver trans-

plantation in an attempt to eradicate the entire biliarytract without dissecting the hepatoduodenal ligament[7]. The rationale of this surgical approach was to com-ply with principles of surgical oncology which prove tobe worthwhile in the resective treatment of other solidorgan tumors, wide resection margins, no dissectionwithin tumorous tissue, and a selection of less advancedtumor stages.

Patients and methods

From April 1992 to April 1996, extended bile duct resections wereperformed in 14 patients, while a total of 80 patients underwentvarious resective procedures of hilar cholangiocarcinomas from1989 to 1996. The mean age of patients undergoing extended bileduct resections was 50.4 ± 9.3 years; 9 patients were male, and5 patients female. The preoperative evaluation comprised tumor

S. JonasN. KlingO. GuckelbergerH. KeckW.O.BechsteinP.Neuhaus

Orthotopic liver transplantationafter extended bile duct resection astreatment of hilar cholangiocarcinomaFirst long-terms results

S.Jonas ()) × N. Kling × O. Guckelberger ×H. Keck × W. O.Bechstein × P. NeuhausChirurgische Klinik, Virchow Klinikumder Humboldt Universität,Augustenburger Platz 1, D-13353 Berlin,Germany

Abstract Although the surgicaltreatment of hilar cholangiocarcino-ma represents the only potentiallycurative option, survival figures re-main low over the long term. Afterhilar and partial hepatic resectionsfor hilar cholangiocarcinoma, loco-regional tumor recurrence appearsas the primary site of failure. FromApril 1992 to April 1996, 14 patientsunderwent extended bile duct resec-tions. Extended bile duct resectionscombine total hepatectomy, partialpancreatoduodenectomy, and livertransplantation in an attempt to era-dicate the entire biliary tract withoutdissecting the hepatoduodenal liga-ment. The postoperative 60-daymortality rate was 14% (n = 2).Therate of curative resections was 93%

(13 of 14 extended bile duct resec-tions). One- and 4-year survivalrates after curative resections were56% and 30%, respectively. The rateof curative resections increased bycombining total hepatectomy, par-tial pancreatoduodenectomy, and li-ver transplantation, i. e., extendedbile duct resection. However, survi-val figures have not improved ac-cordingly. Therefore, this extendedsurgical procedure has to be imple-mented with caution and possiblynot without modifications (e. g.,multimodal treatment).

Key words Hilarcholangiocarcinoma × Extended bileduct resection × Livertransplantation

Transpl Int (1998) 11 [Suppl 1]: S 206±S208Ó Springer-Verlag 1998 LIVER

markers, ultrasound, ERC and brush cytology, angiography, CT(later also MRT), and laparoscopy.

The resection line of extended bile duct resections included li-ver, hepatoduodenal ligament, pancreatic head, distal stomach,duodenum, vena cava, and all lymph nodes at the lesser curvatureand at the right side of the aorta down to the renal vessels. The ret-roperitoneal layer was incised from Gerota's fascia of the right kid-ney to the abdominal wall and the entire connective tissue includ-ing lymphatics, perirenal fat, and suprarenal vena cava inferiorwas dissected en bloc together with the organ cluster, thereby leav-ing the biliary system and hilar cholangiocarcinoma completely un-touched. In addition, the right upper quadrant was deperitonea-lized. Liver transplantation was performed using a venovenous by-pass. The pancreatic tail and bile duct were anastomosed in an end-to-side technique to a single Roux-en-Y jejunal loop.

Immunosuppression followed a standard quadruple inductionprotocol with CsA, steroids, azathioprine, and ATG; the concomi-tant treatment has been described previously [4]. The patients didnot undergo a pre- or postoperative multimodal therapy.

Results

Most hilar cholangiocarcinomas (n = 9) were node posi-tive and locally advanced UICC IVa lesions (UICC I/II:n = 4). In 1 patient, a distant intrapelvic metastasis hadnot been detected until the operation was too advancedand this had also to be resected. The histopathologicaldifferentiation of the tumors was classified as moderate(n = 9) or poor (n = 5). Formally curative resectionswere achieved in 13 of the 14 patients (93%) undergo-ing extended bile duct resections. The postoperative60-day mortality rate after extended bile duct resectionwas 14% (n = 2); 1 patient each from multiorgan failureand bleeding from a late erosion of the hepatic artery.An uncomplicated course was observed in only 1 pa-tient. The main complications arose from the pancreaticremnant, pancreatitis (n = 6; resulting in total pancre-atectomy in 4 patients) and pancreatic fistula (n = 6).Others were bleeding (n = 3), cholangitis (n = 3), wound

infection (n = 2), CMV infection (n = 1), and cellular re-jection (n = 3). All cellular rejections could be associ-ated with low levels of CsA and were successfully trea-ted by conversion to oral tacrolimus. The 1- and 4-yearsurvival figures after formally curative extended bileduct resections were 56% and 30%, respectively(Fig. 1). A tumor recurrence was detected in 8 of the14 patients after extended bile duct resections as perito-neal carcinomatosis (n = 4), as implantation metastasesafter percutaneous draining (n = 2), and after seedingat the terminal ileum (n = 1) and the Roux-en-Y jejuno-jejunostomy (n = 1).

Discussion

An attempted selection of earlier tumor stages for ex-tended bile duct resections could not be achieved, whichpoints to the fact that the current state of diagnosticimaging fails as yet not only to discriminate reliably be-tween benign and malignant lesions of the hepatic con-fluence but also with respect to preoperative staging[10, 11]. However, the rate of curative resections in-creased by combining total hepatectomy, partial pan-creatoduodenectomy, and liver transplantation. In ourexperience, the rates of formally curative resectionsafter hilar or partial hepatic resections approximate30% and 70%, respectively [5].

A comparably favorable effect with respect to survi-val figures was not evident. Survival was mainly im-paired by tumor recurrences which also included im-plantation metastases. At least one metastasis could beattributed to a preoperative percutaneous biliary drai-nage and corroborates previous reports of this implanta-tion pathway in cholangiocarcinoma [9]. A promotingimpact of immunosuppressive therapy on tumor cell ki-netics and recurrence rates has been reported after re-section of hepatocellular carcinoma and may represent

S207

Fig.1 Actuarial patient survi-val after formally curative ex-tended bile duct resections ofhilar cholangiocarcinomas(n = 13)

a specific problem after extended bile duct resectionsfor cholangiocarcinoma as well [13]. Though the truepotential of this procedure remains to be established,

extended bile duct resections have to be implentedonly with caution and possibly not without modifica-tions, such as a multimodal therapeutic concept.

S 208

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