Hilar Cholangiocarcinomas (CCA) were first reported by Altemeir in 1957, described by Gerald Klatskin in a series of 13 patients in 1965 and classified by Bismuth and Corlette in 1975 [1, 2, 3, 4].
Divided into 4 categories according to Bismuth-Corelette classification, Klatskin tumors constitute the most common type of CCAs (40–60%) [5], and second most common primary cancer of the liver (10–15%) after Hepatocellular carcinoma (HCC) [6].
Bismuth Type III Klatskin tumors have always been of greatest interest when dealing with CCAs. These constitute around 60–80% of CCAs and involve the hepatic duct bifurcation, either extending into the right hepatic duct (Type IIIa) or left hepatic duct (Type IIIb) [2].
Surgical resection remains the only curative intervention in Type III Klatskin tumors [7]. These tumors exhibit a high degree of lymphovascular invasion and lymphangiosis carcinomatosa extending up to 2 cm away from the tumor towards the liver and into the hepatoduodenal ligament [8, 9]. Moreover, direct infiltration into the liver is frequent owing to the location of these tumors at the hepatic hilar plate [10].
Therefore, Type IIIa Klatskin tumors are treated with a right hepatectomy involving En-bloc resection of segments VI, VII and VIII, right hepatic artery and portal vein, right extrahepatic bile ducts and portal lymphadenectomy. Right extended hepatectomy, involving resection of additional segments IV a&b is also possible when needed, in the context of a good left hepatic remnant [7]. Type IIIb Klatskin tumors are treated with a left hepatectomy involving En-bloc resection of segments II, III and IV a&b, left hepatic artery and portal vein, left extrahepatic bile ducts and portal lymphadenectomy. Left extended hepatectomy, involving resection of additional segments V and VIII is also possible when needed, in the context of a good right hepatic remnant [11]. Segment I, aka Caudate Lobe, is to be resected if invaded or to close proximity to the tumor, but systemic resection was dropped out of the usual practice nowadays [7].
Many studies attempted to find prognostic factors for long term survival and predisposing factors for postoperative bile leak in order to optimize the approach towards this kind of tumors.
Bile leakage after hepatic resection predicts a bad prognosis [12]. It is associated with high-risk surgical interventions, in which, the cut surface exposed the major Glisson Sheath and included the hepatic hilum, a wide surface hepatectomy, advanced age, high postoperative white blood cell count, prolonged surgery time and left sided hepatectomy [12, 13, 14]. Very few studies handled bile leakage after liver resection for Klatskin tumors exclusively.
As for long term survival in Klatskin tumors, it remains a major subject of interest. Due to the aggressive nature of these cholangiocarcinomas, many factors have been studied in order to optimize the approach towards it, and try to achieve the maximal long term survival: R0 resection, lymph nodes harvesting, appropriate perioperative patient preparation… [15].
Hence, we decided to isolate 23 patients with exclusively Type III a&b Klatskin Tumors, operated at our institution, and investigate the association between clinicopathological features and postoperative morbidity, bile leak in particular, and long-term survival.