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Invited Critique
Gerald W. Peskin, MD
Oakland, Calif
Arch Surg. 2001;136:215.
Like many other reports in the literature of the 1990s, this study of 77 patients with carcinoma of the extrahepatic bile ducts expresses the opinion that an aggressive surgical approach to these lesions can result in a higher percentage of long-term survivors with modest perioperative morbidity and mortality.
By "aggressive in approach," one implies adequate preoperative assessment using computed tomography scans, duplex ultrasonography, endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography, and angiography as needed to establish a staging system that will refine the operative intervention of those individuals who can undergo curative resection. Furthermore, for those lesions involving the confluence of the hepatic ducts, the real decision area of cholangiocarcinoma, aggressiveness means the ability and willingness to resect segments of the liver (the caudate lobe in particular) to achieve negative margins and a reasonable long-term survival. While the Rochester group's series confirms 1990s results, only 2 patients underwent hepatic resection, and only 9 of 45 patients with hilar lesions were resected for cure. Knowing that surgical excision is the only effective means of prolonging the life of these patients, today's surgeons should strive for at least 70% resectability by extending the operation in keeping with the natural history of this tumor.
As Dr Warshaw1 noted almost 8 years ago, "[this] is a retrospective view of where we have been. It will be interesting to see how much further we can go."
REFERENCES
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1. Warshaw AL. Invited critique: outcomes after curative resections of cholangiocarcinoma. Arch Surg. 1993;128:879.
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