Preoperative management of patients undergoing liver resection for perihilar cholangiocarcinoma

Surgical resection with negative margins is the standard treatment for perihilar cholangiocarcinoma whenever possible. Patient’s frequent low performance status at presentation and need of extended resections require optimization of the patient’s condition in the preoperative setting. Biliary drainage is mandatory in case of cholangitis, jaundice-related liver insufficiency, malnutrition or renal failure. Drainage is also necessary in case of portal vein embolization (PVE), in order to improve regeneration of the future liver remnant (FLR). Unilateral drainage of the FLR should be obtained, while bilateral drainage is required in case of cholangitis, slow reduction in bilirubin and uncertainty about the side of resection. The technique for biliary drainage should be decided according to the local expertise and other factors (need of further evaluation of tumour extension, patient’s compliance, necessity of bilateral drainage). Preoperative symbiotics-reduce postoperative infections. PVE is safe and increases the safety of surgery in case of extended liver resections. It is indicated in case of low FLR volume (<40%), low FLR function or in case of previous cholangitis. ALPPS is not recommended in case of PHC.