Klatskin tumor is a type of bile duct cancer that often occurs in patients above age 60-70 years old presenting with yellowing of the eyes (jaundice) and skin itchiness. The cancer originates from the inner lining of the bile duct and eventually obstruct the bile duct itself causing bile from the liver not able to drain into the small bowel. Due to the small size of the tumor, the diagnosis is often late (not visible by the regular CT scans or Ultrasonography imaging). To further complicate the matter, Klatskin tumor is located in a very difficult and tight location, under the liver, wedged by the vessels that bring blood to feed the liver, called hepatic artery and portal vein. Often, the bile duct cancer presents in a late/advanced stage, where the cancer has invaded into the hepatic artery and portal vein, preventing its resectability and cure.
The main treatment of Klatskin tumor and any bile duct cancer is complete surgical resection to remove the cancer and its associated surrounding lymphnodes. Traditionally, the bile duct resection for cancer will be followed by biliary reconstruction surgery in the from of hepaticojejunostomy (creating a new connection between the healthy part of bile duct and the small intestine to allow for biliary drainage).
Bile duct resection surgery is a technically demanding operation due to proximity of the cancer to the neighboring vessels that bring blood to the liver. Intraoperative or delayed bleeding (pseudoaneurysm) can occur from these vessels and liver damage (ischemia) can be seen when the operation is not performed by appropriate surgeons with expertise in liver and bile duct cancer surgery. Anatomical variation of the biliary tree and hepatic vessel is common, making the operation more challenging. Magnification glass is often necessary to visualize this area well. When the bile duct cancer is extending up into the liver, the patient will then require liver resection during the same operation, which can also be performed via robotic liver resection, similar to the robotic liver resection to remove primary or metastatic liver cancers. Not many liver surgeons are equipped to do this operation due to lack of training and experience in robotic liver surgery.
Once the bile duct cancer resection is done, the next step will be bile duct reconstruction surgery or some people call it bile duct replacement surgery. The surgeon brings a loop of small bowel to be used to create a new bile duct. This way, the bile from the liver can drain into the small intestine like in the normal way. Dr Sucandy is a hepatobiliary surgeon with expertise in bile duct cancer or Klatskin tumor treatment. Dr. Sucandy sees and treats patients from the Tampa Bay Area, east cost of Florida and even from out of states.
Recently, Dr Sucandy presented his outcomes of the modern approach in bile duct cancer resection surgery. This paper was also presented at Journal of Surgical Oncology*, available for public to read. Robotic klatskin tumor treatment is an alternative to the historical open klatskin tumor resection, now using a minimally invasive technique. In his recent publication, he concluded that robotic Klatskin tumor resection is safe, feasible and reproducible with excellent outcomes. Blood loss and postoperative complications are low with rapid return to daily activities, while maintaining oncological aspect of complete tumor resection. The robotic approach in bile duct cancer surgery is the future and this is expected to gain further adoption in the US. The limiting factor at this point is the availability of expert surgeon such as Dr Sucandy in the operation to teach others in the field of liver and biliary cancer surgery. Dr Sucandy is currently an instructor and proctor for robotic liver resection/robotic liver surgery to teach other liver surgeons to learn to do this operation.
*Sucandy I, Shapera E, Jacob K, Luberice K, Crespo K, Syblis C, Ross SB, Rosemurgy AS. Robotic resection of extrahepatic cholangiocarcinoma: Institutional outcomes of bile duct cancer surgery using a minimally invasive technique. J Surg Oncol. 2021 Sep 15. doi: 10.1002/jso.26674. Epub ahead of print. PMID: 34524689.