As most patients with hilar cholangiocarcinoma have obstructive jaundice at the time of diagnosis, ultrasonography followed by multidetector row-CT (MDCT) should be performed for staging of the lesion before biliary drainage. As an expected surgical procedure and future remnant liver can be designed by MDCT, unilateral biliary drainage of the future remnant liver should be carried out with endoscopic nasobiliary drainage (ENBD) or percutaneous transhepatic biliary drainage (PTBD). These external
drainage procedures have another advantage in taking selective cholangiography to make precise diagnoses of progress of cancer along the intrahepatic segmental ducts (Fig. 26.1). Percutaneous transhepatic or peroral cholangioscopy is sometimes useful to define the extension of superficially spreading cholangiocarcinoma. From these findings, resection and reconstruction of the intrahepatic sectional, segmental, and/or subsegmental ducts can be planned prior to surgery. If segmental cholangitis develops prior to surgery, urgent PTBD should be performed to drain the contralateral side of the intrahepatic duct or isolated intrahepatic segmental or subsegmental ducts.

In cases of major hepatectomy, particularly right hepatectomy, and right or left trisectionectomy, portal vein embolization (PVE) should be considered to increase the volume and functional capacity of the future remnant liver (see Chapter 18). It is important to note, however, that many patients have atrophy of the ipsilateral lobe, which results in significant hypertrophy of the future liver remnant, thereby obviating the need for PVE. Volumetric assessment is an important preoperative maneuver.

Bile replacement during external biliary drainage should be performed to restore the intestinal barrier function and prevent bacterial translocation. Also synbiotic agents should be administered pre- and postoperatively to prevent perioperative infectious complications.

As biliary branches for the caudate lobe are involved in most of the cases of hilar cholangiocarcinoma, which separate the right and left hepatic duct, the caudate lobe resection (see Chapter 22) is usually performed to establish an R0 resection, and the smallest necessary hepatic segmentectomy or sectionectomy with caudate lobectomy was designed to minimize the volume of the impaired cholestatic liver resection during 1980s. After developing preoperative PVE, hemihepatectomy, or trisectionectomy has been performed to increase the resectability of advanced carcinoma and safety of major hepatectomy (Figs. 26.2, 26.3). Advances in vascular surgical techniques in hepatobiliary surgery have allowed combined liver and portal vein and/or hepatic artery resection and reconstruction with acceptable morbidity and mortality rates for locally advanced tumors.