Klatskin Tumors and the Accuracy of the Bismuth-Corlette Classification ANDREAS PAUL, M.D.,* GERNOT M. KAISER, M.D.,* ERNESTO P. MOLMENTI, M.D., M.B.A.,*{ TOBIAS SCHROEDER, M.D.,† SPIRIDON VERNADAKIS, M.D.,* ARZU OEZCELIK, M.D.,* HIDEO A. BABA, M.D.,‡ VITO R. CICINNATI, M.D.,§ GEORGIOS C. SOTIROPOULOS, M.D.* From the Departments of *General, Visceral, and Transplantation Surgery and †Diagnostic and Interventional Radiology and Neuroradiology, the ‡Institute of Pathology and Neuropathology, and the §Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany, and the {Department of Surgery, North Shore University Hospital, Manhasset, New York The Bismuth-Corlette (BC) classification is the current preoperative standard to assess hilar chol- angiocarcinomas (HC). The aim of this study is to evaluate the accuracy, sensitivity, and prognostic value of the BC classification. Data of patients undergoing resection for HC were analyzed. Endo- scopic retrograde cholangiography and standard computed tomography were undertaken in all cases. Additional 3D-CT-reconstructions, magnetic resonance imaging, and percutaneous trans- hepatic cholangiography were obtained in selected patients. A systematic review and meta-analysis of the literature was performed. Ninety patients underwent resection of the hilar bile duct conflu- ence, with right or left hemihepatectomy in 68 instances. The overall accuracy of the BC classification was 48 per cent. Rates of BC under- and over-estimation were 29 per cent and 23 per cent, re- spectively. The addition of MRI, 3D-CT-reconstructions, or percutaneous transhepatic cholangiog- raphy improved the accuracy to 49 per cent (P 5 1.0), 53 per cent (P 5 0.074), and 64 per cent (P \ 0.001), respectively. Lowest sensitivity rates were for BC Type IIIA/IIIB tumors. Meta-analysis of published BC data corresponding to 540 patients did not reach significance. The BC classification has low accuracy and no prognostic value in cases of HC undergoing resection. M ORE THAN 50 YEARS after the first reported re- sections 1, 2 and over 40 years after Klatskin’s description, 3 the treatment of hilar cholangiocarcinoma remains a major challenge. Lesions tend to be slow growing with low metastatic propensity, but diagnosis is usually coincident with obstructive jaundice. 4 Surgical resection remains the only curative approach, with op- timal results achieved in cases of tumor free margins (R0 resections). 5–15 The ‘‘no-touch’’ right trisectionec- tomy with en bloc portal vein and bile duct resection is reported as an independent prognostic factor for sur- vival after curative resection. 16 Extended resections however, entail physiologically viable remnant paren- chyma to avoid postoperative liver failure. Furthermore, because cholestasis negatively impacts liver regeneration, preoperative drainage by endoscopic retrograde cholan- giography (ERC) or percutaneous transhepatic cholangi- ography (PTC) is the ‘‘standard’’ approach. The Bismuth-Corlette (BC) classification 17, 18 pro- vides preoperative assessment of local spread, and classifies Klatskin tumors as Type I (below the con- fluence of the left and right hepatic ducts), Type II (reaching the confluence), Types IIIA and IIIB (oc- cluding the common hepatic duct and the right or left hepatic ducts, respectively), and Type IV (involving the confluence and both the right and left hepatic ducts). Despite its worldwide application however, little in- formation on its predictive accuracy is available. The purpose of our study was to evaluate: 1) the overall accuracy of the BC classification, 2) the impact of various imaging/endoscopic methods on the accu- racy of the BC classification, 3) the sensitivity of the BC classification according to tumor types, and 4) the prognostic accuracy of the BC classification according to a meta-analysis of the literature. Patients and Methods Data of 90 patients who underwent surgical re- section for Klatskin tumor at the Department of Gen- eral, Visceral, and Transplantation Surgery, University Hospital Essen, Germany within a 9-year period were Address correspondence and reprint requests to Georgios C. Sotiropoulos, M.D., Department of General, Visceral, and Trans- plantation Surgery, University Hospital Essen, Hufelandstraße 55, 45122 Essen, Germany. E-mail: georgios.sotiropoulos@uni-due.de or gsotirop@yahoo.com. 1695