Die ERC ist der diagnostisch Goldstandard bei Patienten mit Klatskintumor und kann auch zur palliativen Stenttherapie eingesetzt werden. Wir konnten die Morbidität und Mortalität der post-ERC-Cholangitis bei Patienten mit Klatskintumor deutlich reduzieren, in dem wir nach MRCP-gestützter Bestimmung des Drainageziels nur eine unilaterale Kontrastierung und Stenteinlage durchführten. Die DNA-Zytometrie war der beste Prognosefaktore für das postoperative Überleben von resezierten Patienten mit Klatskintumor. Im Gegensatz zu diploiden und polyploiden Klatskintumoren hatten Patienten mit aneuploiden Tumoren trotz kurativer Resektion eine sehr schlechte Prognose infolge früher Mikrometastasierung. Bei einigen Patienten mit Klatskintumor liegt eine Billroth II-Gastro-Jejunostomie vor. Trotz der erschwerten Endokoppassage gelang es uns meistens, sowohl die Majorpapille zu erreichen, als auch trotz der inversen Endoskopposition eine sichere Papillotomie durchzuführen. Die perkutane Drainagetherapie mittels PTCD ist eine wertvolle Alternative zur transpapillären Stenttherapie. Als kurative Therapie bei nicht-resezierbaren Cholangiokarzinomen werden Lebertransplantationen durchgeführt. Damit assoziierte biliäre Komplikationen konnten bei uns in den meisten Fällen erfolgreich durch endoskopische Therapie behandelt werden. / ERC is considered as the diagnostic gold standard for patients with Klatskin tumor and can be also used for palliative stenting. We could reduce morbidity as well as mortality due to post-ERC-cholangitis performing MRCP-guided identification of the drainage target and subsequently unilateral contrasting and stenting. DNA-cytomtery was the best prognostic factor predicting the postoperative survival propability of patients with cholangiocarinoma. In contrast to patients resected due to diploid or polyploid Klatskin tumors patients with aneuploid tumors suffered from a bad prognosis due to early micrometastasis. Some patients afflicted from Klatskin tumors have a Billroth II gastro-jejunostomy. In spite of the more difficult endoscopic passage we were mostly able to advance the endoscope to the major papille and to perform a save papillotomy. The percutaneous drainage therapy by means of PTCD is an important alternative to transpapillary stenting. Liver transplantation is performed to cure patients with unresectable Klatskin tumor. Biliary complications which occur after transplantations can be successfully treated in most cases by means of endoscopic therapy.

Background: The association of body mass index (BMI) and long-term prognosis and outcome of patients with perihilar cholangiocarcinoma (pCCA) has not been well defined. The aim of this study was to evaluate clinicopathologic and oncologic outcomes with pCCA undergoing resection, according to their BMI. Methods: Patients undergoing liver resection in curative intention for pCCA at a tertiary German hepatobiliary (HPB) center were identified from a prospective database. Patients were classified as normal weight (BMI 18.5–24.9 kg/m2), overweight (BMI 25.0–29.9 kg/m2) and obese (>30 kg/m2) according to their BMI. Impact of clinical and histo-pathological characteristics on recurrence-free survival (RFS) were assessed using Cox proportional hazard regression analysis among patients of all BMI groups. Results: Among a total of 95 patients undergoing liver resection in curative intention for pCCA in the analytic cohort, 48 patients (50.5%) had normal weight, 33 (34.7%) were overweight and 14 patients (14.7%) were obese. After a median follow-up of 4.3 ± 2.9 years, recurrence was observed in totally 53 patients (56%). The cumulative recurrence probability was higher in obese and overweight patients than normal weight patients (5-year recurrence rate: obese: 82% versus overweight: 81% versus normal weight: 58% at 5 years; p = 0.02). Totally, 1-, 3-, 5- and 10-year recurrence-free survival rates were 68.5%, 44.6%, 28.9% and 13%, respectively. On multivariable analysis, increased BMI (HR 1.08, 95% CI: 1.01–1.16; p = 0.021), poor/moderate tumor differentiation (HR 2.49, 95% CI: 1.2–5.2; p = 0.014), positive lymph node status (HR 2.01, 95% CI: 1.11–3.65; p = 0.021), positive resection margins (HR 1.89, 95% CI:1.02–3.4; p = 0.019) and positive perineural invasion (HR 2.92, 95% CI: 1.02–8.3; p = 0.045) were independent prognostic risk factors for inferior RFS. Conclusion: Our study shows that a high BMI is significantly associated with an increased risk of recurrence after liver resection in curative intention for pCCA. This factor should be considered in future studies to better predict patient’s individual prognosis and outcome based on their BMI.

Objectives: In our study, we evaluated and compared the prognostic value and performance of the 6th, 7th, and 8th editions of the American Joint Committee on Cancer (AJCC) staging system in patients undergoing surgery for perihilar cholangiocarcinoma (PHC). Methods: Patients undergoing liver surgery with curative intention for PHC between 2002 and 2019 were identified from a prospective database. Histopathological parameters and stage of the PHC were assessed according to the 6th, 7th, and 8th editions of the tumor node metastasis (TNM) classification. The prognostic accuracy between staging systems was compared using the area under the receiver operating characteristic curve (AUC) model. Results: Data for a total of 95 patients undergoing liver resection for PHC were analyzed. The median overall survival time was 21 months (95% CI 8.1–33.9), and the three- and five-year survival rates were 46.1% and 36.2%, respectively. Staging according to the 8th edition vs. the 7th edition resulted in the reclassification of 25 patients (26.3%). The log-rank p-values for the 7th and 8th editions were highly statistically significant (p ≤ 0.01) compared to the 6th edition (p = 0.035). The AJCC 8th edition staging system showed a trend to better discrimination, with an AUC of 0.69 (95% CI: 0.52–0.84) compared to 0.61 (95% CI: 0.51–0.73) for the 7th edition. Multivariate survival analysis revealed male gender, age >65 years, positive resection margins, presence of distant metastases, poorly tumor differentiation, and lymph node involvement, such as no caudate lobe resection, as independent predictors of poor survival (p < 0.05). Conclusions: In the current study, the newly released 8th edition of AJCC staging system showed no significant benefit compared to the previous 7th edition in predicting the prognosis of patients undergoing liver resection for perihilar cholangiocarcinoma. Further research may help to improve the prognostic value of the AJCC staging system for PHC—for instance, by identifying new prognostic markers or staging criteria, which may improve that individual patient’s outcome.

Le cholangiocarcinome (CC) est une tumeur maligne au pronostic péjoratif dont le traitement repose sur la résection chirurgicale. Il représente 3 % de l’ensemble des cancers digestifs et il est la deuxième tumeur primitive du foie, en fréquence, derrière le carcinome hépatocellulaire. L’âge moyen est de 70 ans avec une prédominance masculine. On distingue actuellement les cholangiocarcinomes intra et extra-hépatiques. La survie est inférieure à 5% à 5 ans tous stades confondues. 60 à 70 % sont des tumeurs de la convergence des canaux biliaires appelées également tumeurs de Klatskin.Le but de ce travail était de répondre aux interrogations persistantes concernant le cholangiocarcinome péri-hilaire (CCPH) en appliquant différentes méthodes statistiques sur différentes bases de données et revue de la littérature.Les trois axes principaux de ce travail s’articulent selon la temporalité de prise en charge, du diagnostic aux suites post-opératoires en passant par la mise en condition préopératoire.Le premier axe repose sur une base de données locale (registre de cancer digestif du Calvados). Les résultats montrent que le CCPH constitue seulement un tiers des cholangiocarcinomes dans la population générale, que son taux d’incidence est stable avec néanmoins une diminution d’incidence, bien que non-significative, chez les femmes ayant un CCPH et que le sexe féminin est un facteur pronostic négatif pour la survie à 5 ans. Le deuxième axe concernait la prise en charge préopératoire des patients, notamment l’optimisation préopératoire du foie restant par le drainage biliaire. Ce travail repose sur deux méta-analyses. Il a permis de mettre en évidence la supériorité de la voie radiologique sur la voie endoscopique concernant les complications liées à la procédure mais en revanche, l’absence de différence significative sur la morbi-mortalité post-résection hépatique, la survie à 5 ans, la survie sans récidive et le taux de dissémination liée à la procédure quand les procédures sont étudiées en intention de traiter. Nos résultats suggèrent qu’un mauvais choix de voie d’abord pour réaliser le drainage biliaire conduit à des échecs répétés qui influencent la récidive tumorale et donc la survie. Le troisième axe s’intéressait aux facteurs pronostiques de morbi-mortalité immédiates post-résection hépatique à partir d’une base de données Européenne (base de l’association Française de chirurgie). Les résultats montrent que la surface corporelle ≥ 1.82 m², l’hyperbilirubinémie > 50 µmol/l et la résection hépatique droite sont des facteurs prédictifs indépendants influençant la mortalité post-opératoire à 30 jours. / Cholangiocarcinoma (CC) is a malignant tumor with a poor prognosis. Its treatment is based on surgical resection. It accounts for 3% of all digestive cancers and is the second primary tumor of the liver, in frequency, after hepatocellular carcinoma. The average age is 70 years old with male predominance. At present intra and extrahepatic cholangiocarcinomas are distinguished. Survival rate is less than 5% at 5 years in all stages. 60 to 70% are tumors of the biliary convergence also called Klatskin tumors.The aim of this work was to answer persistent questions about peri-hilar cholangiocarcinoma (PHCC) by applying different statistical methods on different databases and review of the literature.The three main axes of this work are articulated according to the temporality of management, from the diagnosis to the postoperative follow-up, going through the preoperative setting.The first axis is based on a local database (registry of digestive cancer of Calvados). The results show that PHCC accounts for only one third of cholangiocarcinomas in the general population, that its incidence rate is stable with a decrease in incidence, although not significant, in women having PHCC and that female gender is a negative prognostic factor for 5-year survival. The second axis concerned the preoperative management of patients, including preoperative optimization of the remaining liver by biliary drainage. This work is based on two Meta-analyzes. It made it possible to highlight the superiority of the radiological way in the endoscopic way concerning the complications related to the procedure but on the other hand, the absence of significant difference on the morbi-mortality post hepatic resection, the survival at 5 years, the recurrence free survival and the rate of dissemination related to the procedure when the procedures are studied in intent to treat. Our results suggest that a poor choice of pathway for achieving biliary drainage leads to repeated failures that influence tumor recurrence and thus survival. The third axis was concerned with the prognostic factors of immediate morbidity and mortality after hepatic resection from a European database (base of the French association of surgery). The results show that body surface area ≥ 1.82 m², hyperbilirubinemia > 50 μmol / l and right hepatic resection are independent predictors influencing post-operative mortality at 30 days.