The role of resection and transplantation in cholangiocarcinomas

Surgical resection represents the backbone of a curative therapeutic approach for cholangiocarcinomas. Precise understanding of the individual anatomy and intrahepatic location of the tumor is essential to achieve margin-free resections with low associated complication rates. Hereby, the management of the volume and function of the future liver remnant shapes the preoperative preparation. Below a future liver remnant volume of 50%, preoperative hyperbilirubinemia increases the risk of postoperative morbidity. Therefore, bile duct drainage by endoscopic stenting or percutaneous transhepatic drainage should be performed especially before extensive partial liver resections. For both intrahepatic (iCCA) and perihilar cholangiocarcinomas (pCCA), achievement of a curative R0 resection justifies major liver resections. The limit of functional resectability can hereby be raised by hypertrophy induction. Surgical resection is always the treatment of choice for resectable cholangiocarcinomas. In case of irresectability, evaluation for liver transplantation can be proposed for certain cases of iCCA and pCCA. In the presence of lymph node metastases, the oncological benefit of radical resection is reduced for the above-mentioned entities. The extent of surgical radicality should therefore be adapted to the tumor biology, including a planned (vascular) R1 resection with the goal to minimize postoperative morbidity. A "tailored" surgical concept and close interdisciplinary collaboration are hallmarks of an optimized surgical approach in the context of emerging multimodal strategies.