Copyright ©The Author(s) 2020.
World J Gastroenterol. Jul 7, 2020; 26(25): 3542-3561
Published online Jul 7, 2020. doi: 10.3748/wjg.v26.i25.3542
Table 1 Patients that should undergo to screening programs and the techniques that should be applied
Predisposing factorsDiagnostic techniqueWorrisome features
Intrahepatic lithiasis and recurrent pyogenic cholangitisMRStenosis progression, distal bile duct dilatation, intraductal polypoid mass > 1 cm.
PSCMR + ERCPIrregular bile duct stenosis, bilateral bile duct dilatation, ipsilateral lobar atrophy. ERCP bile duct sampling can simplify differential diagnosis.
Intrahepatic flukeUS/MRCentral intrahepatic and main bile duct dilation with stenosis identificationa.
Table 2 Main advantages of two the two techniques available to obtain bile duct drainage
Internal stent: Less patient discomfort[5]External drainage: Increased patient discomfort[5]
Reduced risk of seeding[73]Higher expertise needed[108]
Higher rate of bacterial contamination/cholangitis[76]Higher rate of hemorrhage[76]
“One shot” microbiological examinationNever cross the malignant bile duct stenosis[5]
Removed during surgeryRepeated cholangiography and microbiological samples
Useful during and after surgery
Table 3 Criteria that can be used to identify non-resectable patients
Absolute criteriaRelative criteria
Presence of distant metastasis (especially liver, lung, peritoneum)Longitudinal and lateral disseminationConsider adequate staging (avoid R1-2)
Extra-regional lymphnode involvement (para-aortic and extraperitoneal)
Bilateral intrahepatic involvement of biliary tree that exclude bilio-enteric anastomosisPortal infiltration < 2 cmPortal vein resection needed
Infiltration or occlusion of the main portal trunk proximal to bifurcation
Right lobe atrophy associated to contralateral portal vein infiltration or portal occlusion > 2 cmLow remant liverConsider liver hypertrophy techniques
Right lobe atrophy associated to contralateral tumor extension more than to 2 cm from hepatic hilum
Contralateral invasion of hepatic arteryType IV pCCCHigh expertise; consider en-bloc resection
Unilobar secondary bile ducts invasion associated to contralateral infiltration or collusion of portal vein
Table 4 Articles reporting resection of type IV perihilar cholangiocarncioma according di bismuth
AuthorPublication yearResection rate (%)Resected cases (n)Vascular resection (n)Vascular reconstruction (n)Vascular invasion at histological evaluation (n)Complications (%)N+ (%)R0 (%)Patient survival 1-3-5 yr (%)
Hu HJ2018NA6952146339578676-44-22
Li B2017NA14242NANANA377535-12-3
Ebata T201850216131NA136 PV + 53 HA19207268-34-22
Ji GW2017NA254413137695NA
Hoffman K2015NA31 (+29 tipo II e III)31122111952366084-38-181
Han IW201421336NA12 PV + 13 HANA3654NA-28-NA
Cheng QB201261101 (+75 tipo III)NANANA25407689-38-133