Journal Review in Hepatobiliary Surgery: Resecting Perihilar Cholangiocarcinoma

Behind The Knife: The Surgery Podcast

Science, Health & Fitness, Medicine, Education

4.8 • 1.4K Ratings

🗓️ 6 October 2025

⏱️ 36 minutes

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Summary

Surgical resection of perihilar cholangiocarcinoma (pCCA) is one of the highest-risk elective operations performed. The obstructive jaundice suffered by patients preoperatively, central location of the tumors, and extensive nature of the resection make pCCA one of the most challenging HPB disease processes. In this episode from the HPB team at Behind the Knife, listen in on the discussion about perioperative strategies to improve outcomes for surgical resection of perihilar cholangiocarcinoma.

Hosts
Anish J. Jain MD (@anishjayjain) is a current PGY4 General Surgery Resident at Stanford University and a former T32 Research Fellow at the University of Texas MD Anderson Cancer Center.

Timothy E. Newhook MD, FACS (@timnewhook19) is an Assistant Professor within the Department of Surgical Oncology at the University of Texas MD Anderson Cancer Center. He is also the associate program director of the HPB fellowship.

Jean-Nicolas Vauthey MD, FACS (@VautheyMD) is Professor of Surgery and Chief of the HPB Section, as well as the Dallas/Fort Worth Living Legend Chair of Cancer Research in the Department of Surgical Oncology at The University of Texas MD Anderson Cancer Center.

Learning Objectives
· Develop an understanding of the three treatment sequences for resection of disease in patients with synchronous liver metastasis from a primary rectal cancer (reverse, combined, and classic approach)
· Develop an understanding of the benefits, risks, and nuances of each of the three treatment sequences
· Develop an understanding of which patient cases each treatment sequence is ideal for as well as which cases they are not suitable for.

Papers Referenced:
1) Ribero D, Zimmitti G, Aloia TA, Shindoh J, Fabio F, Amisano M, Passot G, Ferrero A, Vauthey JN. Preoperative Cholangitis and Future Liver Remnant Volume Determine the Risk of Liver Failure in Patients Undergoing Resection for Hilar Cholangiocarcinoma. J Am Coll Surg. 2016 Jul;223(1):87-97. https://pubmed.ncbi.nlm.nih.gov/27049784/

2) Jain AJ, Lendoire M, Haddad A, Tzeng CD, Boyev A, Maki H, Chun YS, Arvide EM, Lee S, Hu I, Pant S, Javle M, Tran Cao HS, Vauthey JN, Newhook TE. Improved Outcomes Following Resection of Perihilar Cholangiocarcinoma: A 27-Year Experience. Ann Surg Oncol. 2025 Jun;32(6):4352-4362. https://pubmed.ncbi.nlm.nih.gov/40000564/

Additional Suggested Reading
Olthof PB, Erdmann JI, Alikhanov R, Charco R, Guglielmi A, Hagendoorn J, Hakeem A, Hoogwater FJH, Jarnagin WR, Kazemier G, Lang H, Maithel SK, Malago M, Malik HZ, Nadalin S, Neumann U, Olde Damink SWM, Pratschke J, Ratti F, Ravaioli M, Roberts KJ, Schadde E, Schnitzbauer AA, Sparrelid E, Topal B, Troisi RI, Groot Koerkamp B; Perihilar Cholangiocarcinoma Collaboration Group. Higher Postoperative Mortality and Inferior Survival After Right-Sided Liver Resection for Perihilar Cholangiocarcinoma: Left-Sided Resection is Preferred When Possible. Ann Surg Oncol. 2024 Jul;31(7):4405-4412. https://pubmed.ncbi.nlm.nih.gov/38472674/

Mueller M, Breuer E, Mizuno T, Bartsch F, et al. Perihilar Cholangiocarcinoma - Novel Benchmark Values for Surgical and Oncological Outcomes From 24 Expert Centers. Ann Surg. 2021 Nov 1;274(5):780-788. https://pubmed.ncbi.nlm.nih.gov/34334638/

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Transcript

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0:00.0	Behind the Night,. This is your
0:27.3	HPB team at the MD Anderson Cancer Center in Houston. I'm a niche, a general surgery resident
0:33.0	at Stanford and former T-32 Feld M.D. Anderson, and I'm excited to be joined again by my mentors, Dr. Tim Newhook,
0:40.3	and Jean-Noclizvote, the HB section chief.
0:44.4	Today we'll be discussing peri-hiler-clangiacarcinoma, specifically we'll review articles regarding
0:49.4	the significant morbidity associated with surgical resection of this disease, pre-operative management strategies to reduce post-operative morbidity associated with surgical resection of this disease, pre-operative management strategies
0:56.0	to reduce post-operative morbidity, and changes in our surgical approach over time that have
1:01.6	also improved outcomes. Just to give our listeners some context, perihyler-calangio is a relatively
1:07.8	uncommon neoplasm that originates from the malignant transformation of the epithelia
1:13.6	and the proximal biode duct, and the tumor typically involves the biliary confluence,
1:17.6	but can occasionally extend to the second and third order of biliary branches.
1:21.6	For patients suffering from perihiliclangeo without metastatic disease,
1:26.6	the only potentially curative options for treatment are either transplantation of the liver or complete surgical resection.
1:34.2	However, surgical resection of perihylerclangio is one of the highest risk elective operations we perform, with reported morbidity rates greater than 60% and 90-day mortality rates greater than 10% in large
1:46.8	multi-center studies. So the first thing I want to ask you both, and Dr. Newark,
1:51.6	we can start with you, is what makes the surgical resection of perihyler-clanger carcinoma
1:56.6	so challenging? Well, it seems like a very directed question, but it's actually a very broad
2:01.9	question because there's many different considerations that need to be taking in account when
2:06.2	considering resection for a patient with this disease. And I should say when I explain it to
2:11.9	patients as well, it's actually quite amazing how many things need to be taken into account
2:16.7	for something in such a small area.
2:20.3	This disease is particularly challenging from a circuitical perspective primarily because of anatomy.
	...

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