Patient with 50 years - old with painless jaundice ( 13,5 ng/dl) , she presented a stopping at hepatic hylum diagnosed by both CT and Colangioresonance ( she was classified as Type 2 from Bismuth Classification). This patient presented severe obesity and she was unfit to an enlarged resection( with any hepatectomy including a single caudate lobectomy). So, we only proposed an open supra-pancreatic billiary resection which included the totally of the roof confluence, intrahepatic bylio-enteric (righ and left ) bypass besides that a hilar and celiac lymphadenectomy. She has carried out without any complication at ten postoperative day. The histological analysis revealed a 2,5 cm low-grade infiltrative adenocarcinoma of the main billiary duct with intense desmoplasia and free margins, besides one comprised lymphnode hepatic hylum (1/12 ). The final diagnoses was T2N1MX ( TNM-UICC Classification). She underwent a postoperative chemoradiotherapy . Nowadays, fifty years after her surgery ,She presents none recurrence.
In my opinion, though an enlarged resection with en bloc Hepatectomy has been considered the best therapeutic approach, eventually just biliar resection could be a less agressive resection curative intent like we have observed in this case report.
I agree with Dr Pais-Costa comments, because very often is obliged to complement with a partial hepatectomy
As long as you have negative proximal margins, liver resection is not mandatory in type 1 and 2 cholangios. Bile duct resection is sufficient..
In my opinion, a caudate lobe resection should be included in all type 2 klatskin tumors and so I always try to perform an anatomical left or right resection including the caudate lobe. Left or right depending on the anatomy and the liver remnant. Of course, if the patient is not suitable for such an aggressive surgery, a biliary resection with negative margins should be considered.
I would add that this limited biliary resection can be also very challenging as you may be prepared to deal with multiple right biliary ducts, depending on how proximal you must go to get clear margins, and a left duct and thus at least two hepatico-jejunostomies should be done. This situation may be followed by more complications in terms of biliary leakage than a liver resection with one anastomosis.
The most important pronostico sign is to have the free margins and no adenapathies in the surgical piece reseted
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