Annals of Hepato-Biliary-Pancreatic Surgery (한국간담췌외과학회지)

The Korean Association of Hepato-Biliary-Pancreatic Surgery (한국간담췌외과학회)
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Surgical management of hilar cholangiocarcinoma: Controversies and recommendations

  • Suvendu Sekhar Jena (Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital) ;
  • Naimish N Mehta (Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital) ;
  • Samiran Nundy (Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital)
  • Received : 2023.03.07
  • Accepted : 2023.04.17
  • Published : 2023.08.31
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Abstract

Hilar cholangiocarcinomas are highly aggressive malignancies. They are usually at an advanced stage at initial presentation. Surgical resection with negative margins is the standard of management. It provides the only chance of cure. Liver transplantation has increased the number of 'curative' procedures for cases previously considered to be unresectable. Meticulous and thorough preoperative planning is required to prevent fatal post-operative complications. Extended resection procedures, including hepatic trisectionectomy for Bismuth type IV tumors, hepatopancreaticoduodenectomy for tumors with extensive longitudinal spread, and combined vascular resection with reconstruction for tumors involving hepatic vascular structures, are challenging procedures with surgical indications expanded. Liver transplantation after the standardization of a neoadjuvant protocol described by the Mayo Clinic has increased the number of patients who can undergo operation.

Keywords

References

  1. de Jong MC, Marques H, Clary BM, Bauer TW, Marsh JW, Ribero D, et al. The impact of portal vein resection on outcomes for hilar cholangiocarcinoma: a multi-institutional analysis of 305 cases. Cancer 2012;118:4737-4747. 
  2. Altemeier WA, Gall EA, Zinninger MM, Hoxworth PI. Sclerosing carcinoma of the major intrahepatic bile ducts. AMA Arch Surg 1957;75:450-460; discussion 460-461. 
  3. Klatskin G. Adenocarcinoma of the hepatic duct at its bifurcation within the porta hepatis. An unusual tumor with distinctive clinical and pathological features. Am J Med 1965;38:241-256. 
  4. Saxena A, Chua TC, Chu FC, Morris DL. Improved outcomes after aggressive surgical resection of hilar cholangiocarcinoma: a critical analysis of recurrence and survival. Am J Surg 2011;202:310-320. 
  5. Choi JY, Kim MJ, Lee JM, Kim KW, Lee JY, Han JK, et al. Hilar cholangiocarcinoma: role of preoperative imaging with sonography, MDCT, MRI, and direct cholangiography. AJR Am J Roentgenol 2008;191:1448-1457. 
  6. Jarnagin WR, Fong Y, DeMatteo RP, Gonen M, Burke EC, Bodniewicz BSJ, et al. Staging, resectability, and outcome in 225 patients with hilar cholangiocarcinoma. Ann Surg 2001;234:507-517; discussion 517-519. 
  7. Xiang S, Lau WY, Chen XP. Hilar cholangiocarcinoma: controversies on the extent of surgical resection aiming at cure. Int J Colorectal Dis 2015;30:159-171. 
  8. Bismuth H, Nakache R, Diamond T. Management strategies in resection for hilar cholangiocarcinoma. Ann Surg 1992;215:31-38. 
  9. Blechacz BR, Sanchez W, Gores GJ. A conceptual proposal for staging ductal cholangiocarcinoma. Curr Opin Gastroenterol 2009;25:238-239. 
  10. Deoliveira ML, Schulick RD, Nimura Y, Rosen C, Gores G, Neuhaus P, et al. New staging system and a registry for perihilar cholangiocarcinoma. Hepatology 2011;53:1363-1371. 
  11. Gaspersz MP, Buettner S, van Vugt JLA, de Jonge J, Polak WG, Doukas M, et al. Evaluation of the New American Joint Committee on Cancer staging manual 8th edition for perihilar cholangiocarcinoma. J Gastrointest Surg 2020;24:1612-1618. 
  12. Fausto N, Campbell JS, Riehle KJ. Liver regeneration. Hepatology 2006;43(2 Suppl 1):S45-S53. 
  13. Schweizer W, Duda P, Tanner S, Balsiger D, Hoflin F, Blumgart LH, et al. Experimental atrophy/hypertrophy complex (AHC) of the liver: portal vein, but not bile duct obstruction, is the main driving force for the development of AHC in the rat. J Hepatol 1995;23:71-78. 
  14. May BJ, Madoff DC. Portal vein embolization: rationale, technique, and current application. Semin Intervent Radiol 2012;29:81-89. 
  15. Maundura M, Koea JB. Assessment and optimization of the future liver remnant. In: Abdeldayem HM, ed. Updates in liver cancer. IntechOpen, 2017:165. 
  16. Makuuchi M, Thai BL, Takayasu K, Takayama T, Kosuge T, Gunven P, et al. Preoperative portal embolization to increase safety of major hepatectomy for hilar bile duct carcinoma: a preliminary report. Surgery 1990;107:521-527. 
  17. Ikeda K, Kinoshita H, Hirohashi K, Kubo S, Kaneda K. The ultrastructure, kinetics and intralobular distribution of apoptotic hepatocytes after portal branch ligation with special reference to their relationship to necrotic hepatocytes. Arch Histol Cytol 1995;58:171-184. 
  18. Di Stefano DR, de Baere T, Denys A, Hakime A, Gorin G, Gillet M, et al. Preoperative percutaneous portal vein embolization: evaluation of adverse events in 188 patients. Radiology 2005;234:625-630. 
  19. Kokudo N, Tada K, Seki M, Ohta H, Azekura K, Ueno M, et al. Proliferative activity of intrahepatic colorectal metastases after preoperative hemihepatic portal vein embolization. Hepatology 2001;34:267-272. 
  20. van Gulik TM, van den Esschert JW, de Graaf W, van Lienden KP, Busch OR, Heger M, et al. Controversies in the use of portal vein embolization. Dig Surg 2008;25:436-444. 
  21. van Lienden KP, van den Esschert JW, de Graaf W, Bipat S, Lameris JS, van Gulik TM, et al. Portal vein embolization before liver resection: a systematic review. Cardiovasc Intervent Radiol 2013;36:25-34. 
  22. Hayashi S, Baba Y, Ueno K, Nakajo M, Kubo F, Ueno S, et al. Acceleration of primary liver tumor growth rate in embolized hepatic lobe after portal vein embolization. Acta Radiol 2007;48:721-727. 
  23. Nagino M, Ando M, Kamiya J, Uesaka K, Sano T, Nimura Y. Liver regeneration after major hepatectomy for biliary cancer. Br J Surg 2001;88:1084-1091. 
  24. Kishi Y, Madoff DC, Abdalla EK, Palavecino M, Ribero D, Chun YS, et al. Is embolization of segment 4 portal veins before extended right hepatectomy justified? Surgery 2008;144:744-751. 
  25. van den Esschert JW, de Graaf W, van Lienden KP, Busch OR, Heger M, van Delden OM, et al. Volumetric and functional recovery of the remnant liver after major liver resection with prior portal vein embolization: recovery after PVE and liver resection. J Gastrointest Surg 2009;13:1464-1469. 
  26. Schadde E, Ardiles V, Robles-Campos R, Malago M, Machado M, Hernandez-Alejandro R, et al.; ALPPS Registry Group. Early survival and safety of ALPPS: first report of the International ALPPS Registry. Ann Surg 2014;260:829-836; discussion 836-838. 
  27. Olthof PB, Coelen RJS, Wiggers JK, Groot Koerkamp B, Malago M, Hernandez-Alejandro R, et al. High mortality after ALPPS for perihilar cholangiocarcinoma: case-control analysis including the first series from the international ALPPS registry. HPB (Oxford) 2017;19:381-387. 
  28. Hernandez-Alejandro R, Bertens KA, Pineda-Solis K, Croome KP. Can we improve the morbidity and mortality associated with the associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) procedure in the management of colorectal liver metastases? Surgery 2015;157:194-201. 
  29. Petrowsky H, Gyori G, de Oliveira M, Lesurtel M, Clavien PA. Is partial-ALPPS safer than ALPPS? A single-center experience. Ann Surg 2015;261:e90-e92. 
  30. Alvarez FA, Ardiles V, Sanchez Claria R, Pekolj J, de Santibanes E. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS): tips and tricks. J Gastrointest Surg 2013;17:814-821. 
  31. Gauzolino R, Castagnet M, Blanleuil ML, Richer JP. The ALPPS technique for bilateral colorectal metastases: three "variations on a theme". Updates Surg 2013;65:141-148. 
  32. Li J, Kantas A, Ittrich H, Koops A, Achilles EG, Fischer L, et al. Avoid "all-touch" by hybrid ALPPS to achieve oncological efficacy. Ann Surg 2016;263:e6-e7. 
  33. Robles R, Parrilla P, Lopez-Conesa A, Brusadin R, de la Pena J, Fuster M, et al. Tourniquet modification of the associating liver partition and portal ligation for staged hepatectomy procedure. Br J Surg 2014;101:1129-1134; discussion 1134. 
  34. Gall TM, Sodergren MH, Frampton AE, Fan R, Spalding DR, Habib NA, et al. Radio-frequency-assisted liver partition with portal vein ligation (RALPP) for liver regeneration. Ann Surg 2015;261:e45-e46. 
  35. Gringeri E, Boetto R, D'Amico FE, Bassi D, Cillo U. Laparoscopic microwave ablation and portal vein ligation for staged hepatectomy (LAPS): a minimally invasive first-step approach. Ann Surg 2015;261:e42-e43. 
  36. Teng F, Tang YY, Dai JL, Li Y, Chen ZY. The effect and safety of preoperative biliary drainage in patients with hilar cholangiocarcinoma: an updated meta-analysis. World J Surg Oncol 2020;18:174. 
  37. Nimura Y, Hayakawa N, Kamiya J, Kondo S, Shionoya S. Hepatic segmentectomy with caudate lobe resection for bile duct carcinoma of the hepatic hilus. World J Surg 1990;14:535-543; discussion 544. 
  38. Makuuchi M, Thai BL, Takayasu K, Takayama T, Kosuge T, Gunven P, et al. Preoperative portal embolization to increase safety of major hepatectomy for hilar bile duct carcinoma: a preliminary report. Surgery 1990;107:521-527. 
  39. Wiggers JK, Groot Koerkamp B, Cieslak KP, Doussot A, van Klaveren D, Allen PJ, et al. Postoperative mortality after liver resection for perihilar cholangiocarcinoma: development of a risk score and importance of biliary drainage of the future liver remnant. J Am Coll Surg 2016;223:321-331.e1. 
  40. Kennedy TJ, Yopp A, Qin Y, Zhao B, Guo P, Liu F, et al. Role of preoperative biliary drainage of liver remnant prior to extended liver resection for hilar cholangiocarcinoma. HPB (Oxford) 2009;11:445-451. 
  41. Wronka KM, Grat M, Stypulkowski J, Bik E, Patkowski W, Krawczyk M, et al. Relevance of preoperative hyperbilirubinemia in patients undergoing hepatobiliary resection for hilar cholangiocarcinoma. J Clin Med 2019;8:458. 
  42. Paik WH, Loganathan N, Hwang JH. Preoperative biliary drainage in hilar cholangiocarcinoma: when and how? World J Gastrointest Endosc 2014;6:68-73. 
  43. Hartog H, Ijzermans JN, van Gulik TM, Groot Koerkamp B. Resection of perihilar cholangiocarcinoma. Surg Clin North Am 2016;96:247-267. 
  44. Bird N, Elmasry M, Jones R, Elniel M, Kelly M, Palmer D, et al. Role of staging laparoscopy in the stratification of patients with perihilar cholangiocarcinoma. Br J Surg 2017;104:418-425. 
  45. Coelen RJ, Ruys AT, Wiggers JK, Nio CY, Verheij J, Gouma DJ, et al. Development of a risk score to predict detection of metastasized or locally advanced perihilar cholangiocarcinoma at staging laparoscopy. Ann Surg Oncol 2016;23(Suppl 5):904-910. 
  46. Mantel HT, Westerkamp AC, Sieders E, Peeters PM, de Jong KP, Boer MT, et al. Intraoperative frozen section analysis of the proximal bile ducts in hilar cholangiocarcinoma is of limited value. Cancer Med 2016;5:1373-1380. 
  47. Ribero D, Amisano M, Lo Tesoriere R, Rosso S, Ferrero A, Capussotti L. Additional resection of an intraoperative margin-positive proximal bile duct improves survival in patients with hilar cholangiocarcinoma. Ann Surg 2011;254:776-781; discussion 781-783. 
  48. Ke Q, Chen Y, Huang Q, Lin N, Wang L, Liu J. Does additional resection of a positive microscopic ductal margin benefit patients with perihilar cholangiocarcinoma: a systematic review and meta-analysis. PLoS One 2020;15:e0232590. 
  49. Nooijen LE, Franken LC, de Boer MT, Buttner S, van Dieren S, Koerkamp BG, et al. Value of routine intraoperative frozen sections of proximal bile duct margins in perihilar cholangiocarcinoma, a retrospective multicenter and matched case-control study. Eur J Surg Oncol 2022;48:2424-2431. 
  50. DeOliveira ML, Cunningham SC, Cameron JL, Kamangar F, Winter JM, Lillemoe KD, et al. Cholangiocarcinoma: thirty-one-year experience with 564 patients at a single institution. Ann Surg 2007;245:755-762. 
  51. Endo I, House MG, Klimstra DS, Gonen M, D'Angelica M, Dematteo RP, et al. Clinical significance of intraoperative bile duct margin assessment for hilar cholangiocarcinoma. Ann Surg Oncol 2008;15:2104-2112 
  52. Seyama Y, Kubota K, Sano K, Noie T, Takayama T, Kosuge T, et al. Long-term outcome of extended hemihepatectomy for hilar bile duct cancer with no mortality and high survival rate. Ann Surg 2003;238:73-83. 
  53. Sakamoto E, Nimura Y, Hayakawa N, Kamiya J, Kondo S, Nagino M, et al. The pattern of infiltration at the proximal border of hilar bile duct carcinoma: a histologic analysis of 62 resected cases. Ann Surg 1998;227:405-411. 
  54. Launois B, Terblanche J, Lakehal M, Catheline JM, Bardaxoglou E, Landen S, et al. Proximal bile duct cancer: high resectability rate and 5-year survival. Ann Surg 1999;230:266-275. 
  55. Otani K, Chijiiwa K, Kai M, Ohuchida J, Nagano M, Kondo K. Role of hilar resection in the treatment of hilar cholangiocarcinoma. Hepatogastroenterology 2012;59:696-700. 
  56. Ikeyama T, Nagino M, Oda K, Ebata T, Nishio H, Nimura Y. Surgical approach to bismuth type I and II hilar cholangiocarcinomas: audit of 54 consecutive cases. Ann Surg 2007;246:1052-1057. 
  57. Lim JH, Choi GH, Choi SH, Kim KS, Choi JS, Lee WJ. Liver resection for Bismuth type I and type II hilar cholangiocarcinoma. World J Surg 2013;37:829-837. 
  58. Hosokawa I, Shimizu H, Yoshidome H, Ohtsuka M, Kato A, Yoshitomi H, et al. Surgical strategy for hilar cholangiocarcinoma of the left-side predominance: current role of left trisectionectomy. Ann Surg 2014;259:1178-1185. 
  59. Nagino M, Ebata T, Yokoyama Y, Igami T, Sugawara G, Takahashi Y, et al. Evolution of surgical treatment for perihilar cholangiocarcinoma: a single-center 34-year review of 574 consecutive resections. Ann Surg 2013;258:129-140. 
  60. Jo HS, Kim DS, Yu YD, Kang WH, Yoon KC. Right-side versus left-side hepatectomy for the treatment of hilar cholangiocarcinoma: a comparative study. World J Surg Oncol 2020;18:3. 
  61. Bengmark S, Ekberg H, Evander A, Klofver-Stahl B, Tranberg KG. Major liver resection for hilar cholangiocarcinoma. Ann Surg 1988;207:120-125. 
  62. Yang M, Li WW, Chen JH, Cui MH, Liu JL. The value of caudate lobectomy in hilar cholangiocarcinoma treatment: a meta-analysis. Medicine (Baltimore) 2021;100:e24727. 
  63. Ebata T, Yokoyama Y, Igami T, Sugawara G, Takahashi Y, Nimura Y, et al. Hepatopancreatoduodenectomy for cholangiocarcinoma: a single-center review of 85 consecutive patients. Ann Surg 2012;256:297-305. 
  64. Neuhaus P, Thelen A, Jonas S, Puhl G, Denecke T, Veltzke-Schlieker W, et al. Oncological superiority of hilar en bloc resection for the treatment of hilar cholangiocarcinoma. Ann Surg Oncol 2012;19:1602-1608. 
  65. Wu XS, Dong P, Gu J, Li ML, Wu WG, Lu JH, et al. Combined portal vein resection for hilar cholangiocarcinoma: a meta-analysis of comparative studies. J Gastrointest Surg 2013;17:1107-1115. 
  66. Anderson B, Doyle MBM. Surgical considerations of hilar cholangiocarcinoma. Surg Oncol Clin N Am 2019;28:601-617. 
  67. Nagino M, Nimura Y, Nishio H, Ebata T, Igami T, Matsushita M, et al. Hepatectomy with simultaneous resection of the portal vein and hepatic artery for advanced perihilar cholangiocarcinoma: an audit of 50 consecutive cases. Ann Surg 2010;252:115-123. 
  68. Rela M, Rajalingam R, Shanmugam V, O' Sullivan A, Reddy MS, Heaton N. Novel en-bloc resection of locally advanced hilar cholangiocarcinoma: the Rex recess approach. Hepatobiliary Pancreat Dis Int 2014;13:93-97. 
  69. Li J, Zhou MH, Ma WJ, Li FY, Deng YL. Extended lymphadenectomy in hilar cholangiocarcinoma: what it will bring? World J Gastroenterol 2020;26:3318-3325. 
  70. Bagante F, Tran T, Spolverato G, Ruzzenente A, Buttner S, Ethun CG, et al. Perihilar cholangiocarcinoma: number of nodes examined and optimal lymph node prognostic scheme. J Am Coll Surg 2016;222:750-759.e2. 
  71. Kitagawa Y, Nagino M, Kamiya J, Uesaka K, Sano T, Yamamoto H, et al. Lymph node metastasis from hilar cholangiocarcinoma: audit of 110 patients who underwent regional and paraaortic node dissection. Ann Surg 2001;233:385-392. 
  72. Aoba T, Ebata T, Yokoyama Y, Igami T, Sugawara G, Takahashi Y, et al. Assessment of nodal status for perihilar cholangiocarcinoma: location, number, or ratio of involved nodes. Ann Surg 2013;257:718-725. 
  73. Mantel HT, Wiggers JK, Verheij J, Doff JJ, Sieders E, van Gulik TM, et al. Lymph node micrometastases are associated with worse survival in patients with otherwise node-negative hilar cholangiocarcinoma. Ann Surg Oncol 2015;22 Suppl 3:S1107-S1115. 
  74. Fretland AA, Dagenborg VJ, Bjornelv GMW, Kazaryan AM, Kristiansen R, Fagerland MW, et al. Laparoscopic versus open resection for colorectal liver metastases: the OSLO-COMET randomized controlled trial. Ann Surg 2018;267:199-207. 
  75. Yu H, Wu SD, Chen DX, Zhu G. Laparoscopic resection of Bismuth type I and II hilar cholangiocarcinoma: an audit of 14 cases from two institutions. Dig Surg 2011;28:44-49. 
  76. Gumbs AA, Jarufe N, Gayet B. Minimally invasive approaches to extrapancreatic cholangiocarcinoma. Surg Endosc 2013;27:406-414. 
  77. Zhang Y, Dou C, Wu W, Liu J, Jin L, Hu Z, et al. Total laparoscopic versus open radical resection for hilar cholangiocarcinoma. Surg Endosc 2020;34:4382-4387. 
  78. Ratti F, Fiorentini G, Cipriani F, Catena M, Paganelli M, Aldrighetti L. Perihilar cholangiocarcinoma: are we ready to step towards minimally invasiveness? Updates Surg 2020;72:423-433. 
  79. He YG, Huang W, Ren Q, Li J, Yang FX, Deng CL, et al. Comparison of efficacy and safety between laparoscopic and open radical resection for hilar cholangiocarcinoma-a propensity score-matching analysis. Front Oncol 2022;12:1004974. 
  80. Xu Y, Wang H, Ji W, Tang M, Li H, Leng J, et al. Robotic radical resection for hilar cholangiocarcinoma: perioperative and long-term outcomes of an initial series. Surg Endosc 2016;30:3060-3070. 
  81. Jacoby H, Rayman S, Ross S, Crespo K, Syblis C, Rosemurgy A, et al. Robotic resection of hilar cholangiocarcinoma: a single institution experience. Mini-invasive Surg 2022;6:58. 
  82. Mansour JC, Aloia TA, Crane CH, Heimbach JK, Nagino M, Vauthey JN. Hilar cholangiocarcinoma: expert consensus statement. HPB (Oxford) 2015;17:691-699. 
  83. Iwatsuki S, Todo S, Marsh JW, Madariaga JR, Lee RG, Dvorchik I, et al. Treatment of hilar cholangiocarcinoma (Klatskin tumors) with hepatic resection or transplantation. J Am Coll Surg 1998;187:358-364. 
  84. De Vreede I, Steers JL, Burch PA, Rosen CB, Gunderson LL, Haddock MG, et al. Prolonged disease-free survival after orthotopic liver transplantation plus adjuvant chemoirradiation for cholangiocarcinoma. Liver Transpl 2000;6:309-316. 
  85. Rea DJ, Heimbach JK, Rosen CB, Haddock MG, Alberts SR, Kremers WK, et al. Liver transplantation with neoadjuvant chemoradiation is more effective than resection for hilar cholangiocarcinoma. Ann Surg 2005;242:451-458; discussion 458-461. 
  86. Gores GJ, Gish RG, Sudan D, Rosen CB; MELD Exception Study Group. Model for end-stage liver disease (MELD) exception for cholangiocarcinoma or biliary dysplasia. Liver Transpl 2006;12(12 Suppl 3):S95-S97. 
  87. Zaydfudim VM, Rosen CB, Nagorney DM. Hilar cholangiocarcinoma. Surg Oncol Clin N Am 2014;23:247-263. 
  88. Ethun CG, Lopez-Aguiar AG, Anderson DJ, Adams AB, Fields RC, Doyle MB, et al. Transplantation versus resection for hilar cholangiocarcinoma: an argument for shifting treatment paradigms for resectable disease. Ann Surg 2018;267:797-805. 
  89. Cambridge WA, Fairfield C, Powell JJ, Harrison EM, Soreide K, Wigmore SJ, et al. Meta-analysis and meta-regression of survival after liver transplantation for unresectable perihilar cholangiocarcinoma. Ann Surg 2021;273:240-250. 
  90. Croome KP, Rosen CB, Heimbach JK, Nagorney DM. Is liver transplantation appropriate for patients with potentially resectable de novo hilar cholangiocarcinoma? J Am Coll Surg 2015;221:130-139. 
  91. Gores GJ, Gish RG, Sudan D, Rosen CB; MELD Exception Study Group. Model for end-stage liver disease (MELD) exception for cholangiocarcinoma or biliary dysplasia. Liver Transpl 2006;12(12 Suppl 3):S95-S97. 
  92. Umgelter A, Hapfelmeier A, Kopp W, van Rosmalen M, Rogiers X, Guba M; Eurotransplant Liver Advisory Committee. Disparities in Eurotransplant liver transplantation wait-list outcome between patients with and without model for end-stage liver disease exceptions. Liver Transpl 2017;23:1256-1265. 
  93. Lang SA, Bednarsch J, Czigany Z, Joechle K, Kroh A, Amygdalos I, et al. Liver transplantation in malignant disease. World J Clin Oncol 2021;12:623-645. 
  94. Soares KC, Jarnagin WR. The landmark series: hilar cholangiocarcinoma. Ann Surg Oncol 2021;28:4158-4170. 
  95. Kim KB, Choi DW, Heo JS, Han IW, Shin SH, You Y, et al. The impact of portal vein resection on outcome of hilar cholangiocarcinoma. Ann Hepatobiliary Pancreat Surg 2021;25:221-229. 
  96. Rebelo A, Friedrichs J, Grilli M, Wahbeh N, Partsakhashvili J, Ukkat J, et al. Systematic review and meta-analysis of surgery for hilar cholangiocarcinoma with arterial resection. HPB (Oxford) 2022;24:1600-1614. 
  97. Fancellu A, Sanna V, Deiana G, Ninniri C, Turilli D, Perra T, et al. Current role of hepatopancreatoduodenectomy for the management of gallbladder cancer and extrahepatic cholangiocarcinoma: a systematic review. World J Gastrointest Oncol 2021;13:625-637. 
  98. Dopazo C, Charco R. Liver transplantation for perihilar cholangiocarcinoma. Do we need to move forward? Hepatoma Res 2023;9:10.