Surgical approaches to the management of primary biliary cholangiocarcinoma of the porta hepatis: the decision-making dilemma.

Fifty patients with proximal malignant biliary obstruction confined to or above the junction of the main hepatic ducts underwent surgical treatment. Group A patients (n = 30) underwent complete or partial removal of the tumor with no supplementary procedure, group B patients (n = 20) complete removal of the tumor and a supplementary procedure. Additional procedures were liver resection alone (11/20), and liver resection plus resection and reconstruction of regional vascular structures (9/20). Reconstruction of the intrahepatic biliary tree was carried out in all patients using intrahepatic cholangiojejunostomies between common segmental hepatic stomata and a Roux-en-Y jejunal loop. In each common segmental hepatic stoma, two or three segmental hepatic ducts were drained. Transanastomotic tubes were used only temporarily. Eight patients died, three from group A (3/30) and five from group B (5/20). Survivors were relieved of jaundice and had no subsidiary cholangitis or problems associated with the anastomotic tubes. Seventeen patients of group A and 12 of group B are alive, with a mean survival of 29 and 31 months, respectively. Both alternatives offer good results. The choice of the surgical approach should be based on a precise evaluation of each patient's anatomical and individual clinical peculiarities.