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Bismuth-Corlette

Modified Bismuth-Corlette classification of perihilar cholangiocarcinoma

Five-type map of longitudinal tumor extension through the primary and right/left secondary biliary confluences. It does not encode vascular invasion, lobar atrophy, nodal or distant disease, future liver remnant, resectability or prognosis and cannot prescribe a resection or drainage route by itself.

vigenteBismuth and Corlette / hepatobiliary surgery1975 framework; 1992 modification; 2025 EASL staging boundary1975MRI, CT
Fonte primária5 categorias
IType IIIType IIIIIaType IIIaIIIbType IIIbIVType IV

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Categorias

Reescritas a partir da fonte e citadas
I
1 de 5

Type I

Tumor extends within the common hepatic duct but remains below the primary right-left hepatic-duct confluence; the primary confluence and both right and left secondary ductal confluences are spared. Confirm the map on preintervention MRI/MRCP when possible and state actual ductal variants.

CondutaTreat type I as a longitudinal duct descriptor, not an instruction for bile-duct-only resection, right hepatectomy or ERCP. A specialist hepatobiliary multidisciplinary team determines R0 resection feasibility from the inferior margin, vessels, lobar atrophy, nodes, metastases, future liver remnant, fitness and anatomy. Avoid routine preoperative drainage; when a separate indication exists, route and target are individualized.
RiscoType I has the least proximal ductal extent in this framework but no validated independent survival or resectability probability. Margin feasibility, tumor biology, nodal or distant disease, vascular involvement, future liver remnant and patient fitness dominate prognosis; do not describe type I as low-risk cancer solely from the numeral.
verificadoIntrahepatic cholangioenteric anastomosis in carcinoma of the hilus of the liverBismuth and Corlette 1975, PMID 1079096, original lineage; Bismuth et al. 1992, PMC1242367, modified surgical framework; EASL CPG 2025, DOI 10.1016/j.jhep.2025.03.007, pCCA radiology, staging, resectability, surgery and biliary-drainage sections.
II
2 de 5

Type II

Tumor involves the primary right-left hepatic-duct confluence but spares both the right and left secondary ductal confluences. Mere contact near the hilum is insufficient: report whether the primary confluence is truly infiltrated and whether both secondary confluences remain assessable and free.

CondutaMap both secondary confluences, hepatic artery and portal vein, lobar atrophy, future liver remnant and metastases before deciding resectability or resection extent. Type II does not universally select a right-sided operation or endoscopic drainage. If preoperative drainage is clinically required, target the intended future liver remnant and select endoscopic or percutaneous access from anatomy and expertise rather than type alone.
RiscoType II implies primary-confluence involvement and greater ductal complexity than type I, but the classification has no type-II-specific calibrated prognosis. An anatomically resectable type II with favorable margins and nodes may have a different outlook from a metastatic type I; formal AJCC stage and multidisciplinary resectability variables must remain separate.
verificadoIntrahepatic cholangioenteric anastomosis in carcinoma of the hilus of the liverBismuth-Corlette five-type anatomy as retained in EASL 2025 and Dar et al. 2024 PMC10989497; EASL diagnosis/staging and surgical sections for MRI/MRCP, multiphasic CT, AJCC and non-Bismuth resectability fields; drainage section for indication- and anatomy-led access.
IIIa
3 de 5

Type IIIa

Tumor involves the primary confluence and extends into the RIGHT secondary ductal confluence, while the left secondary confluence remains spared. Map right anterior and posterior sectoral ducts and variants; vague extension into a proximal right duct is not enough when the secondary confluence cannot be assessed.

CondutaA right-sided or extended resection may be considered, but IIIa never automatically means right trisectionectomy. The operative plan depends on actual sectoral anatomy, arterial and portal involvement, ipsilateral or contralateral atrophy, achievable margins and the volume, function and drainage of the future liver remnant. Drainage is not routine and its route cannot be selected from IIIa alone.
RiscoUnilateral secondary-confluence involvement increases reconstruction and margin complexity but supplies no independent IIIa survival percentage. Resectability and outcome depend on contralateral duct preservation, vessels, lobar atrophy, future liver remnant, nodes, metastases, biology and center expertise rather than the suffix a.
verificadoIntrahepatic cholangioenteric anastomosis in carcinoma of the hilus of the liverModified Bismuth-Corlette anatomy in Bismuth et al. 1992, PMC1242367, and current EASL 2025 pCCA sections; Dar et al. 2024, PMC10989497, Bismuth classification, preoperative imaging and surgical-resection factors for type III planning.
IIIb
4 de 5

Type IIIb

Tumor involves the primary confluence and extends into the LEFT secondary ductal confluence, while the right secondary confluence remains spared. Map the left sectoral ducts and any right-sided variant draining into the left system before assigning the side-specific suffix.

CondutaA left-sided or extended resection may be considered, but IIIb never automatically means left trisectionectomy. Determine the side and extent from ductal variants, vascular involvement, lobar atrophy, margins and future liver remnant. If biliary drainage has an independent indication, drain viable intended remnant liver and choose the route through multidisciplinary expertise, not the IIIb token.
RiscoType IIIb indicates unilateral left secondary-confluence extension but is not a prognostic stage or a calibrated operative-risk group. Individual outcome is driven by R0 feasibility, vascular and metastatic disease, nodes, future liver remnant, physiology and treatment pathway. Avoid claiming that IIIa and IIIb have an intrinsic ordinal risk difference.
verificadoIntrahepatic cholangioenteric anastomosis in carcinoma of the hilus of the liverBismuth et al. 1992 modified framework; EASL 2025 MRI/MRCP anatomy, CT vascular/metastatic staging, resectability and drainage guidance; Dar et al. 2024 surgical-planning discussion including biliary extent, atrophy, vascular involvement, dominance and variants.
IV
5 de 5

Type IV

Tumor involves BOTH right and left secondary ductal confluences; modified formulations also include multifocal or discontinuous bilateral ductal disease. Name the exact bilateral confluences or skip lesions and distinguish true tumor from stent-related inflammation or inadequate post-drainage visualization.

CondutaType IV is not automatically unresectable. Expert multidisciplinary assessment may identify selected candidates for complex R0 resection or a protocolized transplant pathway, while metastatic, vascular, remnant-liver or physiologic factors may preclude either. Do not assign trisectionectomy, transplantation or combined endoscopic/percutaneous drainage from the label; each requires its own anatomic and clinical eligibility gate.
RiscoType IV denotes the broadest ductal extent and often high technical complexity, but modern expert centers have resected selected type-IV tumors and the code does not yield an individual survival probability. Prognosis depends on margins, nodes, metastases, vascular involvement, remnant liver, biology, treatment eligibility and response; transplant-series survival must not be attributed to all type-IV patients.
verificadoIntrahepatic cholangioenteric anastomosis in carcinoma of the hilus of the liverModified Bismuth-Corlette bilateral/multifocal definition; EASL 2025 evidence review noting resection across Bismuth types and superiority of broader staging for resectability/survival; EASL surgery, transplant and drainage sections; Dar et al. 2024, selected type-IV surgical boundary.
Lógica de decisão estruturada

Use modified Bismuth-Corlette only for the longitudinal duct map. Always expose confluences, vessels, atrophy, metastases and future liver remnant separately; no type automatically determines resection, drainage, transplant or prognosis.

{
  "categories": [
    {
      "outcome_code": "I",
      "longitudinal_extent": "common_hepatic_duct_below_primary_right_left_confluence",
      "primary_confluence": "spared",
      "right_secondary_confluence": "spared",
      "left_secondary_confluence": "spared"
    },
    {
      "outcome_code": "II",
      "longitudinal_extent": "primary_right_left_hepatic_duct_confluence",
      "primary_confluence": "involved",
      "right_secondary_confluence": "spared",
      "left_secondary_confluence": "spared"
    },
    {
      "outcome_code": "IIIa",
      "longitudinal_extent": "primary_confluence_and_right_secondary_ductal_confluence",
      "primary_confluence": "involved",
      "right_secondary_confluence": "involved",
      "left_secondary_confluence": "spared"
    },
    {
      "outcome_code": "IIIb",
      "longitudinal_extent": "primary_confluence_and_left_secondary_ductal_confluence",
      "primary_confluence": "involved",
      "right_secondary_confluence": "spared",
      "left_secondary_confluence": "involved"
    },
    {
      "outcome_code": "IV",
      "longitudinal_extent": "both_right_and_left_secondary_ductal_confluences_or_multifocal_discontinuous_bilateral_disease",
      "primary_confluence": "usually_involved",
      "right_secondary_confluence": "involved",
      "left_secondary_confluence": "involved"
    }
  ],
  "identity_and_scope": {
    "intended_use": "Describe longitudinal ductal extension of a suspected or confirmed perihilar cholangiocarcinoma before intervention.",
    "classification_unit": "one_perihilar_tumor_at_one_preintervention_staging_timepoint",
    "lineage": "The framework was introduced by Bismuth and Corlette in 1975 and modified in the 1992 surgical strategy publication; identify the current five-type form as modified Bismuth-Corlette.",
    "nomenclature": "Use perihilar cholangiocarcinoma for tumors arising at the hepatic hilum; retain hilar or Klatskin only as recognized synonyms when matching source records.",
    "outside_scope": [
      "vascular_invasion",
      "lobar_atrophy",
      "nodal_stage",
      "distant_metastases",
      "future_liver_remnant",
      "AJCC_stage",
      "Blumgart_stage",
      "resectability",
      "prognosis",
      "automatic_resection_or_drainage_route"
    ]
  },
  "anatomy_gate": {
    "primary_confluence": "Junction of the right and left hepatic ducts forming the common hepatic duct.",
    "secondary_confluences": "First major intrahepatic right and left sectoral duct junctions; right anterior/posterior and left sectoral anatomy or variants must be mapped explicitly.",
    "variant_rule": "Ductal variants can change the surgical meaning of a nominal side. Report the actual ducts involved and do not infer a type from right/left wording without a mapped biliary tree.",
    "longitudinal_only_rule": "Radial mass size or contact with vessels does not change the Bismuth code unless longitudinal ductal involvement crosses a defining confluence."
  },
  "classification_algorithm": [
    {
      "step": 1,
      "if": "both_right_and_left_secondary_confluences_involved_or_multifocal_discontinuous_bilateral_ductal_disease",
      "output_code": "IV"
    },
    {
      "step": 2,
      "if": "primary_confluence_and_right_secondary_confluence_involved_with_left_secondary_confluence_spared",
      "output_code": "IIIa"
    },
    {
      "step": 3,
      "if": "primary_confluence_and_left_secondary_confluence_involved_with_right_secondary_confluence_spared",
      "output_code": "IIIb"
    },
    {
      "step": 4,
      "if": "primary_confluence_involved_and_both_secondary_confluences_spared",
      "output_code": "II"
    },
    {
      "step": 5,
      "if": "tumor_below_primary_confluence_with_confluence_spared",
      "output_code": "I"
    },
    {
      "step": 6,
      "if": "one_or_more_confluences_cannot_be_assessed",
      "output": "indeterminate_or_adjacent_type_range_with_missing_anatomy"
    }
  ],
  "decisive_boundaries": {
    "I_II": "Any primary confluence involvement is at least type II; tumor ending below it is type I.",
    "II_III": "Type II spares both secondary confluences. Extension into the right or left secondary confluence creates IIIa or IIIb respectively.",
    "III_IV": "Unilateral secondary-confluence involvement is type III; bilateral secondary-confluence involvement is type IV.",
    "multifocal_rule": "Discontinuous bilateral ductal foci may be represented as type IV in modified formulations; state the multifocal pattern rather than hiding it behind the numeral.",
    "stent_boundary": "Assign the pretreatment duct map before biliary stenting whenever possible because decompression, inflammation and devices can obscure longitudinal tumor extent."
  },
  "imaging_and_structured_staging": {
    "CT": "Use multiphasic contrast-enhanced CT of chest, abdomen and pelvis to evaluate arterial and portal venous involvement, adjacent invasion, nodes and distant metastases.",
    "MRI_MRCP": "Use contrast-enhanced MRI with MRCP to map the primary and both secondary biliary confluences, longitudinal intraductal extent, satellites and ductal variants.",
    "mandatory_duct_map": [
      "inferior_tumor_margin",
      "primary_confluence",
      "right_secondary_confluence",
      "left_secondary_confluence",
      "right_anterior_and_posterior_sectoral_ducts",
      "left_sectoral_ducts",
      "ductal_variants",
      "multifocal_or_skip_disease"
    ],
    "mandatory_non_Bismuth_fields": [
      "hepatic_artery_contact_as_preserved_fat_plane_abutment_below_180_degrees_encasement_above_180_degrees_stenosis_or_occlusion",
      "portal_vein_contact_as_preserved_fat_plane_abutment_below_180_degrees_encasement_above_180_degrees_stenosis_or_occlusion",
      "lobar_or_segmental_atrophy",
      "adjacent_organ_or_parenchymal_invasion",
      "regional_and_distant_nodes",
      "distant_metastases",
      "future_liver_remnant_volume_quality_and_drainage"
    ],
    "completeness_rule": "A Bismuth code without separate vascular, atrophy, metastatic and future-liver-remnant fields is not a complete resectability assessment."
  },
  "modern_staging_boundary": {
    "AJCC": "Use the current AJCC system for formal anatomic stage rather than treating Bismuth as a cancer stage.",
    "Blumgart": "Blumgart or an equivalent multidisciplinary framework adds portal-vein involvement and lobar atrophy to biliary extent for resectability assessment.",
    "evidence_boundary": "Modern analyses cited by EASL found AJCC more informative for resectability and survival, and expert centers have resected selected tumors across all Bismuth types.",
    "type_IV_rule": "Type IV is not synonymous with unresectable. Determine technical and oncologic resectability from bilateral ductal extent together with vessels, atrophy, metastases, future liver remnant, reconstruction options and center expertise."
  },
  "current_management_context": {
    "multidisciplinary_review": "Every potentially localized perihilar cholangiocarcinoma requires specialist hepatobiliary multidisciplinary review using high-quality preintervention imaging.",
    "resection_goal": "For localized disease, complete R0 resection is the curative-intent surgical goal when anatomically and physiologically feasible.",
    "types_IIIa_IIIb": "IIIa often prompts consideration of a right-sided or extended resection and IIIb a left-sided approach, but the final side and extent depend on ductal variants, vascular involvement, lobar atrophy, future liver remnant and achievable margins.",
    "type_IV": "Selected type-IV tumors may undergo complex resection or a protocolized transplant pathway at expert centers; the Bismuth label alone cannot select either path.",
    "future_liver_remnant": "Planning commonly targets more than 25-30 percent future liver remnant in healthy liver and may require more than 40 percent in perihilar cholangiocarcinoma with prolonged obstruction; volume, function and drainage must be individualized.",
    "biliary_drainage": "Avoid routine preoperative drainage. Consider it for cholangitis, renal failure, intractable pruritus, marked hyperbilirubinemia, neoadjuvant therapy, extensive planned surgery or a long wait; drain the intended future liver remnant when drainage is required.",
    "route_guard": "Do not choose endoscopic versus percutaneous drainage from Bismuth type alone. Current EASL guidance finds insufficient evidence to recommend one route universally for resectable disease requiring drainage.",
    "safety_rule": "Never emit right hepatectomy, left hepatectomy, trisectionectomy, drainage, unresectability or transplant eligibility as an automatic consequence of type I-IV."
  },
  "risk_and_interpretation": {
    "no_per_type_calibration": "No current guideline provides an independent calibrated survival probability for each Bismuth type.",
    "complexity_direction": "Higher ductal extent generally increases reconstruction and margin complexity, but does not monotonically determine operative candidacy or survival.",
    "actual_prognostic_factors": [
      "R0_margin_feasibility",
      "nodal_status",
      "distant_metastases",
      "vascular_invasion",
      "lobar_atrophy",
      "future_liver_remnant",
      "tumor_biology",
      "patient_fitness"
    ],
    "communication_rule": "Describe the exact involved confluences beside the type so a numeral never replaces the surgical anatomy."
  },
  "missing_input_behavior": [
    "If the primary confluence cannot be evaluated, withhold type I versus II and identify the needed MRCP or cholangiographic anatomy.",
    "If a secondary confluence is obscured by a stent or inadequate imaging, return the defensible adjacent range rather than forcing II, III or IV.",
    "If vascular, atrophy, metastatic or future-liver-remnant data are absent, provide the ductal type but mark resectability indeterminate.",
    "If right or left ductal anatomy is variant, name the variant and the specific involved ducts before selecting IIIa or IIIb."
  ],
  "agent_output_contract": [
    "modified_Bismuth_Corlette_type_or_explicit_uncertainty",
    "plain_language_primary_and_secondary_confluence_map",
    "pre_or_post_stent_imaging_provenance",
    "MRI_MRCP_and_multiphasic_CT_adequacy",
    "arterial_portal_venous_atrophy_nodal_and_metastatic_fields_separately",
    "future_liver_remnant_volume_quality_and_drainage",
    "AJCC_or_other_formal_stage_separately_when_available",
    "multidisciplinary_resectability_state_without_type_only_inference",
    "management_context_without_automatic_resection_or_drainage_route"
  ],
  "supporting_sources": [
    {
      "role": "original_framework",
      "citation": "Bismuth and Corlette. Surg Gynecol Obstet. 1975;140:170-178",
      "pmid": "1079096"
    },
    {
      "role": "modified_surgical_framework",
      "citation": "Bismuth et al. Ann Surg. 1992;215:31-38",
      "doi": "10.1097/00000658-199201000-00005",
      "pmid": "1309988",
      "pmcid": "PMC1242367"
    },
    {
      "role": "current_European_staging_and_management_context",
      "citation": "EASL CPG. J Hepatol. 2025;83:211-238",
      "doi": "10.1016/j.jhep.2025.03.007",
      "pmid": "40348685"
    },
    {
      "role": "current_multidisciplinary_anatomic_context",
      "citation": "Dar et al. World J Gastroenterol. 2024;30:1018-1042",
      "doi": "10.3748/wjg.v30.i9.1018",
      "pmid": "38577184",
      "pmcid": "PMC10989497"
    }
  ],
  "source_locator": "Bismuth and Corlette 1975, PMID 1079096, and Bismuth, Nakache and Diamond 1992, DOI 10.1097/00000658-199201000-00005, for classification lineage. EASL extrahepatic cholangiocarcinoma CPG 2025, DOI 10.1016/j.jhep.2025.03.007, sections on diagnosis/staging, radiology, resectability, surgery and biliary drainage. Dar et al. 2024, PMC10989497, Bismuth-Corlette, preoperative imaging, surgical resection and drainage sections for the multidisciplinary anatomy boundary."
}

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