Hepatopancreatoduodenectomy for locally advanced perihilar cholangiocarcinoma: A case report and a plea not to underestimate surgical resectability

Introduction and importance: Cholangiocarcinomas often exhibit longitudinal spread along the hepatic duct and choledocus, resulting in the impossibility to achieve complete resection through either liver resection or pan-creatoduodenectomy. Hepatopancreatoduodenectomy (HPD) has been proposed as a surgical strategy to achieve complete resection, although it is burdened by very high rates of postoperative morbidity and mortality.Case presentation: A 73-year-old patient was diagnosed with locally advanced perihilar cholangiocarcinoma extending from the right hepatic duct to the intrapancreatic choleducus; she underwent surgical evaluation in a secondary hospital without expertise in HPB surgery, and was deemed unresectable with positioning of palliative bare metal stent in the biliary tract. After second opinion evaluation at our centre, the patient was deemed resectable, and underwent HPD after right portal vein embolization. The patient is alive and without recurrence after more than six months from the intervention. Clinical discussion: Although complex and characterized with a high burden of postoperative complications, HPD can be proposed as a curative treatment for locally advanced cholangiocarcinoma. Resectability assessment and preoperative evaluation should be managed in expert surgical centres, through a granular assessment of tumour extension and liver function. In particular, the risk of liver failure should be minimized whenever possible through future liver remnant hypertrophy strategies.Conclusion: Hepatopancreatoduodenectomy is a feasible treatment for locally advanced cholangiocarcinoma, although it requires clinical management in high-volume and skill surgical centres, where failure to rescue from complications is less probable to occur.