Surgical treatment of hilar cholangiocarcinoma in a new era: comparison among leading Eastern and Western centers, Leeds. J Hepatobiliary Pancreat Sci. 2010;17:497-504. [PMID: 19859651 DOI: 10.1007/s00534-009-0203-6]

Improved Outcomes Following Resection of Perihilar Cholangiocarcinoma: A 27-Year Experience

BACKGROUND

Resection of perihilar cholangiocarcinoma (pCCA) is associated with significant perioperative morbidity and mortality. We sought to evaluate surgical outcomes following resection of pCCA over time.

METHODS

Patients who underwent curative-intent resection with hepatectomy for pCCA at a single institution were divided into two cohorts based on date of resection: past cohort (1996-2013), and recent cohort (2014-2023).

RESULTS

The study included 100 patients: 55 (55%) in the past (1996-2013) and 45 (45%) in the recent (2014-2023) cohorts. There were no differences between cohorts in age, sex, or Bismuth-Corlette classification between the two cohorts. Preoperative cholangitis was less common in the recent cohort (31% vs. 53%, p = 0.03). The proportions of right and left hepatectomies were similar in both cohorts. However, for patients with Bismuth-Corlette types I, II, and IV tumors (n = 35), left hepatectomy was more frequently performed in the recent cohort (61% vs. 13%, p = 0.005). There were trends toward lower rates of major complications (38% vs. 55%, p = 0.095) in the recent cohort. There was significantly less perioperative mortality (2% vs. 15%, p = 0.039) and no postoperative hepatic insufficiency in the recent cohort (0% vs. 20%, p = 0.001). Median recurrence-free survival was similar in the past and recent cohorts (29 vs. 37 months, respectively; p = 0.560), but median overall survival was improved in the recent cohort (33 months vs. not reached, p = 0.009).

CONCLUSIONS

Perioperative management to reduce preoperative cholangitis and liver insufficiency, advances in surgical technique, and consideration of left-sided hepatic resection have resulted in significantly improved outcomes in patients undergoing hepatectomy for pCCA.

Systematic review and meta-analysis of surgery for hilar cholangiocarcinoma with arterial resection

BACKGROUND

With the advances in multimodality treatment, an analysis of the outcome of arterial resections (AR) in surgery of cholangiocarcinoma is lacking. The aim of this meta-analysis was to summarize the currently available evidence onof AR for the treatment of cholangiocarcinoma.

METHODS

A systematic literature search was carried out according to PRISMA guidelines.

RESULTS

10 retrospective cohort studies published from 2007 to 2020 with 2530 patients (408 AR group and 2122 control group) were identified. Higher in-hospital mortality rates (6.8% vs 3.3%, OR 2.65, 95% CI [1.27; 5.32], p = 0.009), higher morbidity rates (Clavien-Dindo classification ≥3 ) (52% vs 47%, OR 1.44, 95% CI [1.02; 1.75], p = 0.04) and lower 1-year, 3-year and 5-year survival rates (54% vs 69%, OR 0.55, 95% CI [0.34; 0.91 p = 0.02), (34% vs 38%, OR 0.74, 95% CI [0.55; 0.98, p = 0.03), (18% vs 29%, OR 0.54, 95% CI [0.39; 0.75, p = 0.0002) were observed in the AR group when compared to the control group.

CONCLUSION

Evidence from non-randomized studies shows a higher morbidity and mortality and shorter long-term survival in patients undergoing AR. However, the results are prone to selection bias, and only randomized trials comparing AR and palliative treatments AR might reveal a possible benefit of AR.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO ID 223396.

Preoperative Osteopenia Is Associated with Significantly Shorter Survival in Patients with Perihilar Cholangiocarcinoma

Background: Osteopenia is defined as low bone mineral density (BMD) and has been shown to be associated with outcomes of patients with various cancers. The association between osteopenia and perihilar cholangiocarcinoma is unknown. The aim of this study was to evaluate osteopenia as a prognostic factor in patients with perihilar cholangiocarcinoma. Methods: A total of 58 patients who underwent surgery for perihilar cholangiocarcinoma were retrospectively analyzed. The BMD at the 11th thoracic vertebra was measured using computed tomography scan within one month of surgery. Patients with a BMD < 160 HU were considered to have osteopenia and b BMD ≥ 160 did not have osteopenia. The log-rank test was performed for survival using the Kaplan−Meier method. After adjusting for confounding factors, overall survival was assessed by Cox′s proportional-hazards model. Results: The osteopenia group had 27 (47%) more females than the non-osteopenia group (p = 0.036). Median survival in the osteopenia group was 37 months and in the non-osteopenia group was 61 months (p = 0.034). In multivariable analysis, osteopenia was a significant independent risk factor associated with overall survival in patients with perihilar cholangiocarcinoma (hazard ratio 3.54, 95% confidence interval 1.09−11.54, p = 0.036), along with primary tumor stage. Conclusions: Osteopenia is associated with significantly shorter survival in patients with perihilar cholangiocarcinoma.

Vascular surgery in liver resection

Vascular surgery in liver resection is a standard part of liver transplantation, but is also used in oncological liver surgery. Malignant liver tumors with vascular involvement have a poor prognosis without resection. Surgery is currently the only treatment to provide long-term survival in advanced hepatic malignancy. Even though extended liver resections are increasingly performed, vascular involvement with need of vascular reconstruction is still considered a contraindication for surgery in many institutions. However, vascular resection and reconstruction in liver surgery-despite being complex procedures-are safely performed in specialized centers. The improvements of the postoperative results with reduced postoperative morbidity and mortality are a result of rising surgical and anesthesiological experience and advancements in multimodal treatment concepts with preconditioning measures regarding liver function and systemic treatment options. This review focuses on vascular surgery in oncological liver resections. Even though many surgical techniques were developed and are also used during liver transplantation, this special procedure is not particularly covered within this review article. We provide a summary of vascular reconstruction techniques in oncological liver surgery according to the literature and present also our own experience. We aim to outline the current advances and standards in extended surgical procedures for liver tumors with vascular involvement established in specialized centers, since curative resection improves long-term survival and shifts palliative concepts to curative therapy.

Vascular Resection in Perihilar Cholangiocarcinoma

Among the cholangiocarcinomas, the most common type is perihilar (phCC), accounting for approximately 60% of cases, after which are the distal and then intrahepatic forms. There is no staging system that allows for a comparison of all series and extraction of conclusions that increase the long-term survival rate of this dismal disease. The extension of the resection, which theoretically depends on the type of phCC, is not a closed subject. As surgery is the only known way to achieve a cure, many aggressive approaches have been adopted. Despite extended liver resections and even vascular resections, margins are positive in around one third of patients. In the past two decades, with advances in diagnostic and surgical techniques, surgical outcomes and survival rates have gradually improved, although variability is the rule, with morbidity and mortality rates ranging from 14% to 76% and from 0% to 19%, respectively. Extended hepatectomies and portal vein resection, or even right hepatic artery reconstruction for the left side tumors are frequently needed. Salvage procedures when arterial reconstruction is not feasible, as well as hepatopancreatoduodenectomy, are still under evaluation too. In this article, we discuss the aggressive surgical approach to phCC focused on vascular resection. Disparate results on the surgical treatment of phCC made it impossible to reach clear-cut conclusions.

Surgery With Arterial Resection for Hilar Cholangiocarcinoma: Protocol for a Systematic Review and Meta-analysis

Background

In light of recent advances in multimodality treatment, an analysis of vascular resection outcomes in surgery for hilar cholangiocarcinoma is lacking.

Objective

The aim of this meta-analysis is to summarize the currently available evidence on outcomes of patients undergoing arterial resection for the treatment of hilar cholangiocarcinoma.

Methods

A systematic literature search in the databases PubMed/MEDLINE, Cochrane Library, and CINAHL, and the trial registries ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform will be carried out. Predefined outcomes are mortality (100-day and in-hospital), morbidity (Clavien-Dindo classification, any type of complication), vascular complications (thrombosis or stenosis of the portal vein or hepatic artery, pseudoaneurysms), liver failure, postoperative bleeding, duration of surgery, reoperation rate, length of hospital stay, survival time, actuarial survival (2-, 3-, and 5-year survival), complete/incomplete resection rates, histologic arterial invasion, and lymph node positivity (number of positive lymph nodes and lymph node ratio).

Results

Database searches will commence in December 2020. The meta-analysis will be completed by December 2021.

Conclusions

Our findings will enable us to present the current evidence on the feasibility, safety, and oncological effectiveness of surgery for hilar cholangiocarcinoma with arterial resection. Our data will support health care professionals and patients in their clinical decision-making.

Trial Registration

PROSPERO 223396; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=223396

International Registered Report Identifier (IRRID)

DERR1-10.2196/31212

Prognostic Relevance of the Eighth Edition of TNM Classification for Resected Perihilar Cholangiocarcinoma

OBJECTIVES

In our study, we evaluated and compared the prognostic value and performance of the 6th, 7th, and 8th editions of the American Joint Committee on Cancer (AJCC) staging system in patients undergoing surgery for perihilar cholangiocarcinoma (PHC).

METHODS

Patients undergoing liver surgery with curative intention for PHC between 2002 and 2019 were identified from a prospective database. Histopathological parameters and stage of the PHC were assessed according to the 6th, 7th, and 8th editions of the tumor node metastasis (TNM) classification. The prognostic accuracy between staging systems was compared using the area under the receiver operating characteristic curve (AUC) model.

RESULTS

Data for a total of 95 patients undergoing liver resection for PHC were analyzed. The median overall survival time was 21 months (95% CI 8.1-33.9), and the three- and five-year survival rates were 46.1% and 36.2%, respectively. Staging according to the 8th edition vs. the 7th edition resulted in the reclassification of 25 patients (26.3%). The log-rank p-values for the 7th and 8th editions were highly statistically significant (p ≤ 0.01) compared to the 6th edition (p = 0.035). The AJCC 8th edition staging system showed a trend to better discrimination, with an AUC of 0.69 (95% CI: 0.52-0.84) compared to 0.61 (95% CI: 0.51-0.73) for the 7th edition. Multivariate survival analysis revealed male gender, age >65 years, positive resection margins, presence of distant metastases, poorly tumor differentiation, and lymph node involvement, such as no caudate lobe resection, as independent predictors of poor survival (p < 0.05).

CONCLUSIONS

In the current study, the newly released 8th edition of AJCC staging system showed no significant benefit compared to the previous 7th edition in predicting the prognosis of patients undergoing liver resection for perihilar cholangiocarcinoma. Further research may help to improve the prognostic value of the AJCC staging system for PHC-for instance, by identifying new prognostic markers or staging criteria, which may improve that individual patient's outcome.

Practical review for diagnosis and clinical management of perihilar cholangiocarcinoma

Cholangiocarcinoma (CCC) is the most aggressive malignant tumor of the biliary tract. Perihilar CCC (pCCC) is the most common CCC and is burdened by a complicated diagnostic iter and its anatomical location makes surgical approach burden by poor results. Besides its clinical presentation, a multimodal diagnostic approach should be carried on by a tertiary specialized center to avoid miss-diagnosis. Preoperative staging must consider the extent of liver resection to avoid post-surgical hepatic failure. During staging iter, magnetic resonance can obtain satisfactory cholangiographic images, while invasive techniques should be used if bile duct samples are needed. Consistently, to improve diagnostic potential, bile duct drainage is not necessary in jaundice, while it is indicated in refractory cholangitis or when liver hypertrophy is needed. Once resecability criteria are identified, the extent of liver resection is secondary to the longitudinal spread of CCC. While in the past type IV pCCC was not considered resectable, some authors reported good results after their treatment. Conversely, in selected unresectable cases, liver transplantation could be a valuable option. Adjuvant chemotherapy is the standard of care for resected patients, while neoadjuvant approach has growing evidences. If curative resection is not achieved, radiotherapy can be added to chemotherapy. This multistep curative iter must be carried on in specialized centers. Hence, the aim of this review is to highlight the main steps and pitfalls of the diagnostic and therapeutic approach to pCCC with a peculiar attention to type IV pCCC.

Perineural invasion of hilar cholangiocarcinoma in Chinese population: One center’s experience

BACKGROUND

Hilar cholangiocarcinoma (HCCA) often produces perineural invasion (PNI) extending to extra-biliary sites, while significant confusion in the incidence of PNI in HCCA has occurred in the literature, and the mechanism of that procedure remains unclear.

AIM

To summarize the incidence of PNI in HCCA and to provide the distribution of nerve plexuses around hepatic portal to clinical surgeons.

METHODS

Reported series with PNI in HCCA since 1996 were reviewed. A clinicopathological study was conducted on sections from 75 patients with HCCA to summarize the incidence and modes of PNI. Immunohistochemical stains for CD34 and D2-40 in the cancer tissue were performed to clarify the association of PNI with microvessel and lymph duct. Sections of the hepatoduodenal ligament from autopsy cases were scanned and handled by computer to display the distribution of nerve plexuses around the hepatic portal.

RESULTS

The overall incidence of PNI in this study was 92% (69 of 75 patients), while the rate of PNI in HCCA in the literature ranging from 38% to 100%. The incidence of PNI did not show any remarkable differences among various differentiated groups and Bismuth-Corlette classification groups. Logistic regression analysis identified the depth of tumor invasion was the only factor that correlated significantly with PNI (P < 0.01). In spite of finding tumor cells that could invade microvessels and lymph ducts in HCCA, we did not find tumor cells invaded nerves via microvessels or lymph ducts. Three nerve plexuses in the hepatoduodenal ligament and Glisson’s sheath were classified, and they all surrounded the great vessels very closely.

CONCLUSION

The incidence of PNI of HCCA in Chinese population is around 92% and correlated significantly with a depth of tumor invasion. It also should be considered when stratifying HCCA patients for further treatment.

Evaluation of the utility of prognostic models for patients with resected hilar cholangiocarcinoma

BACKGROUND

Several prognostic systems have been proposed to guide management strategies post-resection for patients with hilar cholangiocarcinoma. The objective of this study was to evaluate the efficacy of these conventional prognostic models, with respect to Overall Survival (OS), on patients in a modern single-centre resectional cohort.

METHOD

Patients diagnosed with hilar cholangiocarcinoma, referred to a supra-regional tertiary referral centre between February 2009 and February 2016, were retrospectively analysed from a prospectively held database linked to Hospital Episode Statistics and Somerset Cancer Registry data.

RESULTS

Two-hundred and one patients were assessed for suitability for surgery. Eighty-three (41%) patients considered to have potentially resectable disease underwent surgical assessment of resectability. Fifty-six (68%) patients proceeded to resection. Multivariate analysis demonstrated that pre-operative Serum CA 19-9 (p = 0.007), Radiological Arterial Involvement (p = 0.005) and Amsterdam Medical Centre (AMC) prognostic model score (p = 0.032) retained significance in association with OS. Multivariate models developed from this cohort out-performed the conventional prognostic systems for OS.

CONCLUSION

The cohort-derived multivariate models demonstrated significantly improved prognostic capability compared to conventional systems in explaining OS.

Surgical Outcomes for Perihilar Cholangiocarcinoma with Vascular Invasion

PURPOSE

To investigate short- and long-term surgical outcomes for patients with perihilar cholangiocarcinoma and vascular invasion.

METHODS

Data from 249 patients who underwent perihilar cholangiocarcinoma surgery between 2000 and 2016 were retrospectively analyzed. Patient evaluations included short-term surgical outcomes following vascular resection and long-term outcomes in cases with histopathological vascular invasion.

RESULTS

Mortality was 3.6% overall; 16% for hepatic artery resections, 5.4% for portal vein resections, and 1.7% in the absence of vascular resection (p = 0.029). No between-group differences were observed in the incidence of Clavien-Dindo grade ≥ 3 complications. The factors related to perioperative mortality were hepatic artery resection (odds ratio [OR] = 25.5), right trisectionectomy (OR = 13.0), and central bisectionectomy (OR = 13.8). Multivariate analysis for overall survival identified several prognostic factors: carcinoembryonic antigen level ≥ 5 ng/mL (hazard ratio [HR] = 1.68), poor differentiation (HR = 2.39), distant metastasis (HR = 1.97), and R1 invasive resection (HR = 2.13). Five-year overall survival for patients with portal vein invasion and M0R0/1cis was 35.6%, significantly worse than the 53.4% for patients with no portal vein invasion and M0R/1cis but better than the 0% for patients with portal vein invasion and M1 or R1. Those with hepatic arterial invasion and M0R0/1cis were 24.7%, significantly worse than the 53.4% for patients with no hepatic arterial invasion and M0R0/1cis but significantly better than the 0% for patients with hepatic arterial invasion and M1 or R1.

CONCLUSION

Short-term outcomes for patients with perihilar cholangiocarcinoma and undergoing vascular resection were poor compared to those without vascular resection. Long-term survival in R0M0 disease was more favorable; aggressive surgery is recommended.

Evaluation of the diagnostic performance of apparent diffusion coefficient (ADC) values on diffusion-weighted magnetic resonance imaging (DWI) in differentiating between benign and metastatic lymph nodes in cases of cholangiocarcinoma

INTRODUCTION

Cholangiocarcinoma (CCA) is the primary tumor found in the bile duct and is associated with a high incidence of lymph node (LN) metastases and poor outcomes. The presence of metastatic lymph nodes, when shown by imaging, can influence patient treatment and prognosis. DWI is a promising, non-invasive imaging technique for differentiating between benign and malignant LNs. Many studies have shown that LN metastases have a lower apparent diffusion coefficient (ADC) value when compared to benign nodes.

OBJECTIVE

To evaluate the performance of ADC values as a basis for diagnosis of LN metastasis in cholangiocarcinoma patients.

MATERIALS AND METHODS

This was a retrospective imaging study that evaluated histopathologically proven intraabdominal LNs in cholangiocarcinoma patients who underwent a 1.5T abdomen MRI with DWI between January 2012 and July 2016. The ADC values and short-axis diameters of the LNs were measured and compared using student's t test. Receiver operating characteristic (ROC) curves were used to determine the threshold.

RESULTS

A total of 120 lymph nodes-85 benign and 35 metastatic-were included. The mean short-axis diameter of the benign LNs (8.34 mm) was significantly lesser than that of the malignant LNs (9.56 mm). Receiver operating characteristic curve analysis using a size criterion of 1 cm yielded a value of 0.63. A diagnostic size criterion of 1 cm for the short axis was applied and yielded an accuracy of 66%, sensitivity/specificity of 41%/75%, and positive/negative predictive value of 34%/80%. The mean ADC values of metastatic (1.31 × 10^-3 mm²/s) LNs were not significantly different from those of non-metastatic LNs (1.29 × 10^-3 mm²/s).

CONCLUSION

There was no difference in terms of ADC value between benign lymph nodes and those with metastatic cholangiocarcinoma. Isolated measurement of the ADC value does not contribute to a diagnosis of lymph node metastasis.

Comparison of the 7th and 8th editions of the American Joint Committee on Cancer Staging Systems for perihilar cholangiocarcinoma

BACKGROUND

The performances of the American Joint Committee on Cancer staging systems of the 7th and 8th edition were compared using a cohort of patients undergoing surgery for perihilar cholangiocarcinoma at 2 tertiary referral Italian hepatobiliary centers.

METHODS

The American Joint Committee on Cancer 7th and 8th edition staging systems were used to classify 214 patients who underwent surgery for perihilar cholangiocarcinoma. The performances of the 2 staging systems were compared using the concordance index.

RESULTS

Using the American Joint Committee on Cancer 7th edition staging system, we found that the 5-year overall survival for stages I, II, and IVa was 71%, 34%, and 34%, while no patients in stages IIIa, IIIb, and IVb survived 5 years. In comparison, when the American Joint Committee on Cancer 8th edition staging system was used, the 5-year overall survival was 71% and 35% in stages I and II, resulting in 23%, 19%, and 22% in stages IIIa, IIIb, and IIIc, respectively. Of note, no patients in stages IVa and IVb survived 5 years. The American Joint Committee on Cancer 8th edition staging system had a slightly better discriminatory ability with a concordance index of 0.624 compared with 0.619 for the American Joint Committee on Cancer 7th edition.

CONCLUSION

The newly released classification American Joint Committee on Cancer 8th edition staging system demonstrated a poor to moderate ability to predict prognosis of patients undergoing liver resection for perihilar cholangiocarcinoma, which was only slightly better than the previous edition. Further refinements are needed to improve the prognostic ability of the American Joint Committee on Cancer staging system for perihilar cholangiocarcinoma.

Meta-analysis of prognostic factors for overall survival in patients with resected hilar cholangiocarcinoma

BACKGROUND

Hilar cholangiocarcinoma is staged using the AJCC staging system. Numerous other prognostically important histopathological and demographic characteristics have been reported. The objective of this meta-analysis was to assess statistically the effect of postresectional tumour characteristics on overall survival of patients undergoing attempted radical curative resection for hilar cholangiocarcinoma.

METHODS

Relevant studies were identified by searching the Ovid MEDLINE and PubMed databases. The search was limited to studies published between 2009 and 2017. Papers referring to intrahepatic or distal cholangiocarcinoma were excluded from review. Data extraction used standard Parmar modifications to determine pooled univariable hazard ratios (HRs).

RESULTS

Twenty-four articles, containing 4599 patients, were assessed quantitatively. In pooled analyses, age (HR 1·16, 95 per cent c.i. 1·04 to 1·28), T category (HR 1·49, 1·30 to 1·70), lymph node involvement (HR 1·78, 1·65 to 1·93), microvascular invasion (HR 1·49, 1·34 to 1·68), perineural invasion (HR 1·54, 1·40 to 1·68) and tumour differentiation (HR 1·54, 1·38 to 1·72) were significant prognostic factors, with low heterogeneity. Portal vein resection (HR 1·54, 1·15 to 1·70) and resection margin status (HR 1·77, 1·57 to 1·99) had significant effects, but with high heterogeneity. Sex, tumour size and preoperative carbohydrate antigen 19-9 levels did not have a statistically significant effect on postoperative prognosis.

CONCLUSION

Several tumour biological variables not included in the seventh edition of the AJCC classification affect overall survival. These require incorporation into prognostic models to ensure a personalized approach to prognostication and treatment.

Resection for Klatskin tumors: technical complexities and results

Klatskin's tumors, actually-redefined as perihilar cholangiocarcinoma (phCCA) do represent 50-70% of all CCAs and develop in a context of chronic inflammation and cholestasis of bile ducts. Surgical resection provides the only chance of cure for this disease but is technically challenging because of the complex, intimate and variable relationship between biliary and vascular structures at this location. Five years survival rates range between 25-45% (median 27-58 months) in case of R0 resection and 0-23% (median 12-21 months) in case of R1 resection respectively. It should be noted that the major costs of high radicality are represented by relative high morbidity and mortality rates (i.e., 20-66% and 0-9% respectively). Considering the fact that radical resection may represent the only curative treatment of phCCA, we focused our review on surgical planning and techniques that may improve resectability rates and outcomes for locally advanced phCCA. The surgical treatment of phCCA can be successful when following aspects have been fulfilled: (I) accurate preoperative diagnostic aimed to identify the tumor in all its details (localization and extension) and to study all the risk factors influencing a posthepatectomy liver failure (PHLF): i.e., liver volume, liver function, liver quality, haemodynamics and patient characteristics; (II) High end surgical skills taking in consideration the local extension of the tumor and the vascular invasion which usually require an extended hepatic resection and often a vascular resection; (III) adequate postoperative management aimed to avoid major complications (i.e., PHLF and biliary complications). These are technically challenging operations and must be performed in a high volume centres by hepato-biliary-pancreas (HBP)-surgeons with experience in microsurgical vascular techniques.

Vascular Reconstruction in Hepatic Malignancy

With surgery for hepatic malignancy, there are poor options for chemotherapy; many patients are deemed unresectable because of vascular involvement or location of tumors. Over the past few decades, advances in surgical technique have allowed resection of these tumors with vascular reconstruction to achieve negative margins and improve chances for survival. This article reviews those reconstruction techniques and outcomes in detail, including in situ perfusion and ex vivo liver surgery, and provides a discussion of implications and operative planning for patients with hepatic malignancy in order to provide surgeons with better understanding of these complicated operations.

Significance of Vascular Resection and Reconstruction in Surgery for Hilar Cholangiocarcinoma: With Special Reference to Hepatic Arterial Resection and Reconstruction

PURPOSE

The aim of this study was to assess the efficacy of combined resection and reconstruction (CRR) of the hepatic artery (HA) in surgery for hilar cholangiocarcinoma (HC).

MATERIALS AND METHOD

Among 172 patients who underwent surgical resection for HC, the following three groups were defined according to the type of vascular reconstruction: VR(-) group, in which neither CRR of the portal vein (PV) nor HA was performed (n = 74); VR-PV group, in which only CRR of the PV was required (n = 54); and VR-A group, in which CRR of the HA was performed either with or without CRR of the PV (n = 44). Clinicopathological variables and clinical outcomes were compared among the three groups.

RESULTS

Although the VR-A group showed significantly more advanced disease than other groups, the R0 resection rate was comparable among the three groups (VR(-), 74 %; VR-PV, 80 %; VR-A, 80 %). The 5-year disease-specific survival rate was also comparable among the three groups (VR(-), 45.6 %; VR-PV, 51.2 %; VR-A, 22.3 %), but tended to be worse in the VR-A group than in the other groups. A similar trend was observed in morbidity rate. Lymph node metastasis was more frequent in the VR-A group (59 %) than in the other groups (VR(-), 33.8 %; VR-PV, 50 %). In the VR-A group, lymph node metastasis (p = 0.004) and adjuvant chemotherapy (p = 0.006) were determined to represent independent prognostic factors for survival according to multivariate analysis.

CONCLUSION

CRR of the HA was considered efficacious in selected patients; however, long-term outcomes of the VR-A group seem unsatisfactory. Treatments additional to surgery may be necessary in cases requiring CRR of the HA.

The Surgical Management of Klatskin Tumours: Has Anything Changed in the Last Decade?

Surgical treatment of hilar cholangiocarcinomas requires complex pre-, intra- and post-operative decision-making. Despite the significant progress in liver surgery over the years, several issues such as the role of pre-operative biliary drainage, portal vein embolisation, staging laparoscopy and neo-adjuvant chemotherapy remain unresolved. Operative strategies such as vascular resection, caudate lobe resection and liver transplant have also been practiced in order to improve R0 resectability and improved survival. The review aims to consolidate evidence from major studies in the last 11 years. Survival data were only included from studies that reported the results in at least 30 patients with 1-year follow-up. A significant number of patients may be prevented an unnecessary laparotomy if they underwent a staging laparoscopy. There remain no guidelines as to when portal vein embolisation or pre-operative biliary drainage should be employed but most studies agree with pre-operative biliary drainage being an absolute indication if portal vein embolisation is performed. Concomitant hepatectomy and caudate lobectomy increases R0 resection but vascular resection cannot be routinely recommended. Liver transplant at specialised centres in selective patients has had impressive results. Guidelines are required for pre-operative biliary drainage and portal vein embolisation and randomised trials are required in order to define the role of vascular resection in achieving a R0 resection and increasing survival.

Perihilar Cholangiocarcinoma: Number of Nodes Examined and Optimal Lymph Node Prognostic Scheme

BACKGROUND

The role of routine lymphadenectomy for perihilar cholangiocarcinoma is still controversial and no study has defined the minimum number of lymph nodes examined (TNLE). We sought to assess the prognostic performance of American Joint Committee on Cancer/Union Internationale Contre le Cancer (7(th) edition) N stage, lymph node ratio, and log odds (LODDS; logarithm of the ratio between metastatic and nonmetastatic nodes) in patients with perihilar cholangiocarcinoma and identify the optimal TNLE to accurately stage patients.

METHODS

A multi-institutional database was queried to identify 437 patients who underwent hepatectomy for perihilar cholangiocarcinoma between 1995 and 2014. The prognostic abilities of the lymph node staging systems were assessed using the Harrell's c-index. A Bayesian model was developed to identify the minimum TNLE.

RESULTS

One hundred and fifty-eight (36.2%) patients had lymph node metastasis. Median TNLE was 3 (interquartile range, 1 to 7). The LODDS had a slightly better prognostic performance than lymph node ratio and American Joint Committee on Cancer, in particular among patients with <4 TNLE (c-index = 0.568). For 2 TNLE, the Bayesian model showed a poor discriminatory ability to distinguish patients with favorable and poor prognosis. When TNLE was >2, the hazard ratio for N1 patients was statistically significant and the hazard ratio for N1 patients increased from 1.51 with 4 TNLE to 2.10 with 10 TNLE. Although the 5-year overall survival of N1 patients was only slightly affected by TNLE, the 5-year overall survival of N0 patients increased significantly with TNLE.

CONCLUSIONS

Perihilar cholangiocarcinoma patients undergoing radical resection should ideally have at least 4 lymph nodes harvested to be accurately staged. In addition, although LODDS performed better at determining prognosis among patients with <4 TNLE, both lymph node ratio and LODDS outperformed compared with American Joint Committee on Cancer N stage among patients with ≥4 TNLE.

Patterns and prognostic value of lymph node dissection for resected perihilar cholangiocarcinoma

BACKGROUND AND AIM

Lymph node metastasis is a major prognostic factor for perihilar cholangiocarcinoma (PHC). However, prognostic significance of extent of node dissection, lymph node ratio (LNR), and number and location of positive nodes remain unclear. We aimed to evaluate whether node status, LNR, or number or location of positive nodes are independent factors for staging in PHC and to determine the minimum requirements for node examination.

METHODS

The Surveillance, Epidemiology, and End Results database was used to identify 1116 resected PHCs from 1998 to 2008. The correlation between nodal status and survival was analyzed retrospectively.

RESULTS

Lymph node metastasis occurred in 43.4% patients and was an independent predictor for overall survival and cancer-specific survival. No survival benefit was observed for an increasing number of node retrieval in node-positive patients. However, in node-negative patients, ≥13 node dissection was of more survival benefit than 3 ≤ total lymph node count (TLNC) ≤ 12 and TLNC < 3 (5-year overall survival: 52.8% vs 39.7% vs 26.3%, P = 0.001; 5-year cancer-specific survival: 60.6% vs 46.3% vs 30.0%, P = 0.001). No difference in survival between patients with regional and distant node involvement was found. Survival for patients with greater than three positive nodes was significantly worse than that for those with three or less (relative ratio: 1.466, P = 0.001). And patients with LNR > 0.27 also had unfavorable prognosis (relative ratio: 1.376, P = 0.001).

CONCLUSIONS

We determined that to adequately assess nodal status of this life-threatening disease, 13 or more nodes retrieval should be considered. Number of positive nodes and LNR rather than location of metastatic nodes may be defined as parameters for staging of PHC.

Improved surgical outcomes for hilar cholangiocarcinoma: changes in surgical procedures and related outcomes based on 40 years of experience at a single institution

PURPOSE

This study aimed to examine the changes in procedures for hilar cholangiocarcinoma (HC) surgery and patient survival following HC surgery over a 40-year period.

METHODS

Between 1974 and 2014, 239 consecutive patients underwent surgery for HC. The changes in perioperative therapy and short- and long-term surgical outcomes were evaluated.

RESULTS

The rates of major hepatectomy (in particular, right hepatectomy) and R0 resection significantly increased. Blood loss, transfusion rate, morbidity, and surgical mortality all significantly decreased. The 5-year disease-specific survival was 9.29 % (n = 38) in 1974-1988, 41.1 % (n = 88) in 1989-2003 and 55.6 % (n = 57) in 2004-2008 (p = 0.0001: 1974-1988 vs 1989-2003, p < 0.0001:1974-1988 vs 2004-2008, p = 0.076: 1989-2003 vs 2004-2008). According to a multivariate analysis, Bismuth classification IV (HR vs I, 2.86), period 1989-2003 (HR vs 1974-1988, 0.31), 2004-2008 (HR vs 1974-1988, 0.26), and R1 or R2 resection (HR vs R0, 2.22) were independent prognostic factors.

CONCLUSION

The surgical outcomes for HC over the 40-year period clearly improved as a result of aggressive surgery and progress in surgical techniques, perioperative management, and diagnostic tools.

Effect evaluation of vascular resection for patients with hilar cholangiocarcinoma: original data and meta-analysis

To evaluate the effect of vascular resection (VR) in surgical management of hilar cholangiocarcinoma (HCCA), this report is used in a clinical analysis and conducted a systematic review, combined other studies, based on meta-analysis. 238 HCCA patients underwent hepatectomy in the Eastern Hepatobiliary Surgery Hospital. Binary logistic regression analysis was performed to investigate the potentially complicated associated factors. Kaplan-Meier test was employed to compare the long-term survival of patients in four groups (R0+PVR-free, R0+PVR, R1, and R2). Meta-analysis was performed using RevMan 4.3.2 software. The results suggested that hepatectomy and HAR were important negative factors from complications (p < 0.01). Compared with patients in other groups, survival of patients in R0+PVR group was worse than R0+PVR-free group, better than R2 group, and similar to R1group with p = 0.001, 0.047, and 0.606, respectively. The results of meta-analysis suggested patients who underwent VR had higher complications rate and mortality rate than patients who did not. Moreover, patients with vascular resection had lower long-term survival rate. VR used to be considered effective to the patients with vascular invasion. However, our study suggests that the surgical decision of undergoing VR should be made cautiously, since VR could diminish the survival time in some cases.

A modified Jarnagin-Blumgart classification better predicts survival for resectable hilar cholangiocarcinoma

Background

Prediction of postoperative survival for hilar cholangiocarcinoma (HCCA) remains difficult although there have been a variety of clinical classification and staging systems. This study was designed to validate and compare some of the major HCCA staging systems in use today. In addition, we sought to build up a new staging system modified from Jarnagin-Blumgart (J-B) classification for HCCA, to predict survival better.

Methods

A total of 154 consecutive cases of HCCA including 95 surgical patients between 2005 and 2014 were enrolled in this study. The clinical and pathological data were recorded retrospectively and three commonly used classification methods: Bismuth-Corlette (B-C) classification, TNM staging, and J-B classification were performed to analyze the correlations with resectability and survival. Chi-square test, Kaplan-Meier analysis, and kappa statistics were used to compare and confirm the relationships between the variables and survival.

Results

For all 154 patients, the resection rate of J-B T1 was 68.6% (48/70), higher than that of J-B T2 (44.8%, P = 0.007). J-B T2 also showed a higher resectability than J-B T3 (19.2%, P = 0.025). There was no significant difference in resectability within the groups B-C type and TNM stages. We set up a new staging system based on J-B classification, tumor differentiation, distant metastasis (N2 or M1 of TNM stage), and resection integrality. The total survival predictive accuracy was 69.5% (kappa = 0.547), higher than that of TNM staging and J-B classification.

Conclusions

J-B classification was more useful than B-C classification, while its value for predicting survival did not exceed TNM staging system. The new staging system, based on J-B classification, provides a better method to stratify HCCA patients during the operation.

Hilar cholangiocarcinoma: controversies on the extent of surgical resection aiming at cure

BACKGROUND

Hilar cholangiocarcinoma is the most common malignant tumor affecting the extrahepatic bile duct. Surgical treatment offers the only possibility of cure, and it requires removal of all tumoral tissues with adequate resection margins. The aims of this review are to summarize the findings and to discuss the controversies on the extent of surgical resection aiming at cure for hilar cholangiocarcinoma.

METHODS

The English medical literatures on hilar cholangiocarcinoma were studied to review on the relevance of adequate resection margins, routine caudate lobe resection, extent of liver resection, and combined vascular resection on perioperative and long-term survival outcomes of patients with resectable hilar cholangiocarcinoma.

RESULTS

Complete resection of tumor represents the most important prognostic factor of long-term survival for hilar cholangiocarcinoma. The primary aim of surgery is to achieve R0 resection. When R1 resection is shown intraoperatively, further resection is recommended. Combined hepatic resection is now generally accepted as a standard procedure even for Bismuth type I/II tumors. Routine caudate lobe resection is also advocated for cure. The extent of hepatic resection remains controversial. Most surgeons recommend major hepatic resection. However, minor hepatic resection has also been advocated in most patients. The decision to carry out right- or left-sided hepatectomy is made according to the predominant site of the lesion. Portal vein resection should be considered when its involvement by tumor is suspected.

CONCLUSION

The curative treatment of hilar cholangiocarcinoma remains challenging. Advances in hepatobiliary techniques have improved the perioperative and long-term survival outcomes of this tumor.

Does the extent of lymphadenectomy, number of lymph nodes, positive lymph node ratio and neutrophil-lymphocyte ratio impact surgical outcome of perihilar cholangiocarcinoma?

BACKGROUND

Lymph node (LN) status is an important predictor of survival following resection of perihilar cholangiocarcinoma (PHCCA). Controversies still exist with regard to the prognostic value of optimum extent of lymphadenectomy, total number of nodes removed, LN ratio (LNR) and neutrophil-lymphocyte ratio (NLR) on overall survival (OS) and disease-free survival (DFS) following PHCCA resection.

METHODS

From 1994 to 2010, 84 PHCCAs were resected; 78 are included in this analysis. Kaplan-Meier survival curves were studied using log-rank statistics to assess which variables affected OS and DFS. The variables that showed statistical significance (P<0.05) on Kaplan-Meier univariate analysis were subjected to multivariate analysis using Cox proportional hazards model.

RESULTS

Five-year OS for node-positive status (n=45) was 10%, whereas node-negative (n=33) OS was 41% (P<0.001). Similarly, 5-year DFS was worse in the node-positive group (8%) than in the node-negative group (36%, P=0.001). There was no difference in 5-year OS (31 vs. 12%, P=0.135) and DFS (22 vs. 16%, P=0.518) between those with regional lymphadenectomy and those who underwent regional plus para-aortic lymphadenectomy, respectively. On univariate analysis, patients with 20 or more LNs removed had worse 5-year OS (0%) when compared with those with less than 20 LNs removed (29%, P=0.047). Moderate/poor tumour differentiation, distant metastasis and LN involvement were independent predictors of OS. Positive LNR had no effect on OS. Vascular invasion and an LNR of at least 0.37 were independent predictors of DFS. NLR had no effect on OS and DFS.

CONCLUSION

Extended lymphadenectomy patients (≥20 LNs) had worse OS when compared with those with more limited (<20 LNs) resection. An LNR of at least 0.37 is an independent predictor of DFS.

Surgical strategy for hilar cholangiocarcinoma of the left-side predominance: current role of left trisectionectomy

OBJECTIVE

To evaluate recent surgical strategy for hilar cholangiocarcinoma (HC) of the left-side predominance.

BACKGROUND

When employing left hemihepatectomy (LH) for HC, vasculobiliary anatomy of the right liver often makes it difficult to achieve a tumor-free margin of the right posterior sectional bile duct (RPSBD). Because left trisectionectomy (LTS) can produce a longer resection margin for the RPSBD, we have expanded the indications for LTS over the last 5 years.

METHODS

Sixty-one consecutive patients underwent left-sided hepatectomy for HC, divided into 2 groups according to the operative periods: period 1 (2001-2007; n = 29) and period 2 (2008-2012; n = 32). Clinicopathological outcomes of the groups were compared. The difference in the length of the resectable RPSBD between LH and LTS was radiologically investigated using multidetector-row computed tomography.

RESULTS

The proportion of LTS increased from 10.3% (3/29) in period 1 to 46.9% (15/32) in period 2. R0 resection rates were also improved in period 2. The most common margin positive site in period 1 was the stump of the proximal bile duct; high rates of positive RPSBD stump were noted after LH. The positive proximal ductal margin ratio decreased significantly in period 2. The difference in the length of resectable RPSBD between LH and LTS was 9.0 ± 1.3 mm. There was no mortality in period 2, even after LTS.

CONCLUSIONS

LTS for HC of the left-side predominance improved R0 resection rates without affecting postoperative mortality. LTS should be aggressively performed in patients with appropriate hepatic function, even if tumors are possibly resectable by LH.

Evolving role of vascular resection and reconstruction in hepatic surgery for malignancy

Primary and secondary hepatic malignancies, including hepatocellular cancer, cholangiocarcinoma and metastatic disease from colorectal cancer continue to increase in incidence worldwide, and remain diseases with a high mortality. Liver resection, with negative margins, is associated with improved survival and better quality of life over nonoperative treatment. As liver resection continues to evolve, aggressive centers are increasingly using vascular resection and reconstruction to achieve negative margins and improve outcomes. As these resections become more common, the morbidity and mortality associated with these complex surgical procedures is decreasing. Currently, resections of the portal vein are becoming routine in major liver and pancreatic resections, and experience with hepatic artery, hepatic vein and inferior vena cava resections is increasing. This review paper looks at the current indications, techniques and outcomes for major vascular resection in hepatic malignancy.

Assessing resectability in cholangiocarcinoma

Assessment of surgical resectability in cholangiocarcinoma is more complicated than other gastrointestinal malignancies and remains unestablished. According to the primary origin and tumor extent, the applied surgical procedure varies from extrahepatic bile duct resection to right or left trisectionectomy concomitant with pancreatoduodenectomy. Portal vein resection and reconstruction during hepatectomy has been feasible. Thanks to the availability of new microscopic surgical techniques, hepatic arterial resection and reconstruction have also come to be applied for locally advanced cholangiocarcinoma cases. These vascular surgical techniques can expand surgical indications for advanced cholangiocarcinoma. On the other hand, determination of the tumor extent or staging still remains difficult and imprecise. The endoscopic approach has come to play significant roles both for preoperative biliary drainage and tumor staging. Estimation of the functional reserve of future remnant liver in cholestatic patients still remains unresolved. Hepatobiliary surgeons should carefully estimate the safety of the surgical procedure in each individual patient requiring extensive hepatobiliary resection. Early establishment of the measurement methods of the functional capacity of future remnant liver is an important and urgent issue for assessing safer surgical resectablity of cholangiocarcinoma.

Isolated caudate lobectomy with pancreatoduodenectomy for a bile duct cancer

BACKGROUND

In patients with distal bile duct cancer involving the hepatic hilus, a major hepatectomy concomitant with pancreatoduodenectomy (HPD) is sometimes ideal to obtain a cancer-free resection margin. However, the surgical invasiveness of HPD is considerable.

PATIENTS AND METHODS

We present our treatment option for patients with distal bile duct cancer showing mucosal spreading to the hepatic hilum associated with impaired liver function. To minimize resection volume of the liver, an isolated caudate lobectomy (CL) with pancreatoduodenectomy (PD) using an anterior liver splitting approach is presented. Liver transection lines and bile duct resection points correspond complete with our standard right and left hemihepatectomies with CL for perihilar cholangiocarcinoma.

RESULTS

Total operation time was 765 min, and pedicle occlusion time was 124 min, respectively. Although the proximal mucosal cancer extension was identified at both the right and the left hepatic ducts, all resection margins were negative for cancer.

CONCLUSIONS

Isolated CL with PD is an alternative radical treatment option for bile duct cancer patients with impaired liver function.

Systematic review and meta-analysis of the role of vascular resection in the treatment of hilar cholangiocarcinoma

BACKGROUND

The management of hilar cholangiocarcinoma has evolved over time and extended liver resection, including the caudate lobe, and major vascular resection and extended lymphadenectomy have become established practice. The benefit of vascular resection has not been investigated.

METHODS

A systematic search of the MEDLINE and EMBASE databases was used to identify studies. A systematic review and a meta-analysis of the available studies were conducted according to PRISMA guidelines. Odds ratios were calculated using the Mantel-Haenszel method. Primary outcome variables assessed included morbidity, mortality, vascular complications and the effect of vascular resection on longterm survival.

RESULTS

Of 411 search results, only 24 studies reported the results of vascular resection in hilar cholangiocarcinoma. Meta-analysis showed increased morbidity and mortality with hepatic artery resection. Portal vein resection was achievable with no impact on postoperative mortality. Vascular resection did not improve negative margin rates and had no impact on longterm survival.

CONCLUSIONS

Portal vein resection does not preclude curative resection; however, it is not routinely recommended unless there is suspicion of tumour invasion. There was no proven survival advantage with portal vein resection. Arterial resection results in higher morbidity and mortality with no proven benefit.

Resection for hilar cholangiocarcinoma: analysis of prognostic factors and the impact of systemic inflammation on long-term outcome

INTRODUCTION

Resection for hilar cholangiocarcinoma is the single hope for long-term survival.

METHODS

Ninety patients underwent curative intent surgery for hilar cholangiocarcinoma between 1996 and 2012. The potential prognostic factors were assessed by univariate (Kaplan-Meier curves and log-rank test) and multivariate analyses (Cox proportional hazards model).

RESULTS

The median overall and disease-free survivals were 26 and 17 months, respectively. The multivariate analysis identified R0 resection (HR = 0.03, 95 % CI 0-0.19, p < 0.001), caudate lobe invasion (HR = 6.33, 95 % CI 1.31-30.46, p = 0.021), adjuvant gemcitabine-based chemotherapy (HR = 0.38, 95 % CI 0.15-0.94, p = 0.037), and the neutrophil-to-lymphocyte ratio (HR = 0.78, 95 % CI 0.62-0.98, p = 0.036) as independent prognostic factors for disease-free survival. The independent prognostic factors for overall survival were R0 resection (HR = 0.03, 95 % CI 0-0.22, p < 0.001), caudate lobe invasion (HR = 11.75, 95 % CI 1.65-83.33, p = 0.014), and adjuvant gemcitabine-based chemotherapy (HR = 0.19, 95 % CI 0.06-0.56, p = 0.003).

CONCLUSIONS

The negative resection margin represents the most important prognostic factor. Adjuvant gemcitabine-based chemotherapy appears to benefit survival. The neutrophil-to-lymphocyte ratio may potentially be used to stratify patients for future clinical trials.

Assessment of nodal status for perihilar cholangiocarcinoma: location, number, or ratio of involved nodes

OBJECTIVE

To analyze lymph node status in resected perihilar cholangiocarcinoma, to clarify which index (ie, location, number, or ratio of involved nodes) is better for staging, and to determine the minimum requirements for node examination.

BACKGROUND

In the TNM classification for perihilar cholangiocarcinoma, the number or ratio of involved nodes is not considered for nodal staging. The minimum requirement for histologic examination of lymph nodes is arbitrary.

METHODS

This study involved 320 patients with perihilar cholangiocarcinoma who underwent resection from January 2000 to December 2009 at Nagoya University Hospital. The relationship between lymph node status and patient survival was retrospectively analyzed.

RESULTS

Total lymph node counts (TLNCs), ie, the number of lymph nodes examined histologically, averaged 12.9 ± 8.3 (range: 1-59). Lymph node metastasis was found in 146 (45.6%) patients and was an independent, powerful prognostic factor. The survival rates were not significantly different between patients with regional node metastasis alone and those with distant node metastasis (19.2% vs 11.5% at 5 years, P = 0.058). The survival for patients with multiple node metastases was significantly worse than that for patients with single metastasis (12.1% vs 27.6% at 5 years, P = 0.002), regardless of the presence or absence of distant lymph node metastasis. The survival for patients with lymph node ratios (LNRs) of 0.2 or less was significantly better than that for patients with LNRs greater than 0.2 (21.4% vs 13.5% at 5 years, P = 0.032). Upon multivariate analysis of the 146 patients with lymph node metastasis, the number of involved nodes (single vs multiple) was identified as an independent prognostic factor (RR of 1.61, P = 0.045), whereas the locations (regional alone vs distant) and ratios (LNR ≤ 0.2 vs LNR > 0.2) of involved nodes were not. When the 148 pN0-R0 patients were divided into 3 groups (ie, those with TLNC ≥ 8, with TLNC = 5, 6, or 7, and with TLNC ≤ 4), survivals were identical between the first and second groups, whereas they were largely different between the former two and the third.

CONCLUSIONS

Lymph node metastasis is a powerful, independent prognostic factor in perihilar cholangiocarcinoma and is better classified based not on location but on the number of involved nodes. To adequately assess nodal status, histologic examination of 5 or more nodes is recommended.

Surgical management trends for cholangiocarcinoma in the USA 1998-2009

BACKGROUND

Surgical advancements have improved outcomes for cholangiocarcinoma (CCA) patients, but this expertise is not uniformly available. This research examines CCA surgical treatment patterns.

METHODS

A retrospective analysis of the U.S. Nationwide Inpatient Sample from 1998-2009 identified CCA patients at high-volume (HV) versus low-volume (LV) hospitals, and teaching versus nonteaching hospitals. We performed multinomial and multivariate logistic regressions to compare differences of surgical treatment between HV vs. LV hospitals, and teaching vs. nonteaching hospitals. Liver resection (LR), pancreaticoduodenectomy, bile duct (BD) resection, and combined liver/BD resection were considered more aggressive therapy than BD stent or bypass.

RESULTS

A total of 32,561 patients with CCA were identified. The proportion receiving surgery declined from 36 to 30 %. There was no increase in the proportion of LRs or combined liver/BD resection. Patients at HV or teaching hospitals were more likely to receive surgical treatment [odds ratio (OR), 1.3, p < 0.001; OR, 1.4, p < 0.001].

DISCUSSION

Despite increasing evidence that surgical resection increases survival, the number of patients receiving surgery has decreased. Although combined liver/BD resection has been advocated as standard management for proximal CCA, the practice has not increased. All patients with CCA should be considered for assessment at a HV teaching hospital.

Perihilar cholangiocarcinoma: a surgeon's viewpoint on current topics

Perihilar cholangiocarcinomas are defined anatomically as "tumors that are located in the extrahepatic biliary tree proximal to the origin of the cystic duct". However, as the boundary between the extrahepatic and intrahepatic bile ducts is not well defined, perihilar cholangiocarcinomas potentially include two types of tumors: one is the "extrahepatic" type, which arises from the large hilar bile duct, and the other is the "intrahepatic" type, which has an intrahepatic component with the invasion of the hepatic hilus. The new TNM staging system published by the International Union Against Cancer (UICC) has been well revised with regard to perihilar cholangiocarcinoma, but it still lacks stratification of patient prognosis and has little applicability for assessing the feasibility of surgical treatment; therefore, further refinement is essential. Most patients with perihilar cholangiocarcinomas present with jaundice, and preoperative biliary drainage is mandatory. Previously, percutaneous transhepatic biliary drainage was used in many centers; however, it is accepted that endoscopic naso-biliary drainage is the most suitable method of preoperative drainage. Portal vein embolization is now widely used as a presurgical treatment for patients undergoing an extended hepatectomy to minimize postoperative liver dysfunction. The surgical resection of a perihilar cholangiocarcinoma is technically demanding and continues to be the most difficult challenge for hepatobiliary surgeons. Because of advances in diagnostic and surgical techniques, surgical outcomes and survival rates after resection have steadily improved. However, survival, especially for patients with lymph node metastasis, is still unsatisfactory, and the establishment of adjuvant chemotherapy is necessary. Further synergy of endoscopists, radiologists, oncologists, and surgeons is required to conquer this intractable disease.

Clinical significance of left trisectionectomy for perihilar cholangiocarcinoma: an appraisal and comparison with left hepatectomy

OBJECTIVE

To review our experiences with left-sided hepatectomy for perihilar cholangiocarcinoma, to compare left hepatectomy with left trisectionectomy, and to evaluate the clinical significance of left trisectionectomy from the viewpoint of surgical oncology.

BACKGROUND

Only 4 large case series have been reported on left trisectionectomy, with only a few patients diagnosed with perihilar cholangiocarcinoma. Therefore, the oncologic advantage of left trisectionectomy compared with left hepatectomy for perihilar cholangiocarcinoma is still unclear.

METHODS

This study involved 201 patients who underwent left-sided hepatectomy for perihilar cholangiocarcinoma (86 trisectionectomies and 115 hepatectomies). Surgical outcome and survival were compared between the 2 types of hepatectomy. The length of the resected right posterior bile duct was also measured.

RESULTS

Patients who underwent trisectionectomy had more advanced tumors, thus requiring combined vascular and/or other organ resection. Operative time and blood loss were significantly greater in trisectionectomy than in hepatectomy; therefore, overall morbidity was significantly higher in the former (59.3% vs 33.0%, P < 0.001). Mortality was similar (1.2% vs 0.9%) in both techniques. The length of the resected supraportal right posterior bile duct was significantly longer in trisectionectomy than in hepatectomy (20.7 ± 6.4 vs 13.6 ± 5.2 mm, P < 0.001). However, there was no difference in length of the infraportal type right posterior bile duct. The percentage of negative radial and distal common bile duct margins was similar, but the percentage of negative right posterior bile duct margins was significantly higher in trisectionectomy than in hepatectomy (97.7% vs 89.6%, P = 0.027). Overall, R0 resection was achieved in 84.9% of patients with trisectionectomy and in 70.4% of patients with hepatectomy (P = 0.019). Survival rates were similar between patients with trisectionectomy and those with hepatectomy (36.8% vs 34.0% at 5-year), despite the fact that the former had more advanced disease.

CONCLUSIONS

Left trisectionectomy for perihilar cholangiocarcinoma, although technically demanding, can be performed with similar mortality rates as left hepatectomy. From an oncologic viewpoint, this operation can increase the number of negative proximal ductal margins, leading to a high proportion of R0 resection, and, in turn, to improved survival rates of patients with advanced left-sided perihilar cholangiocarcinoma.

The prognostic importance of lymphovascular invasion in cholangiocarcinoma above the cystic duct: a new selection criterion for adjuvant therapy?

OBJECTIVE

Criteria for selecting patients to receive adjuvant chemotherapy in cases of resected intrahepatic or hilar cholangiocarcinoma (CC) are lacking. Some clinicians advocate the provision of adjuvant therapy in patients with lymph node (LN)-positive disease; however, nodal assessment is often inadequate. The aim of this study was to identify a surrogate criterion based on primary tumour characteristics.

METHODS

All patients who underwent resection for hilar or intrahepatic CC at a single institution between January 2000 and September 2009 were identified from a prospectively maintained database. Pathological factors were recorded. The primary outcome assessed was overall survival (OS).

RESULTS

In total, 69 patients underwent resection for hilar (n=34) or intrahepatic (n=35) CC. Their median age was 66 years and 27 patients (39%) were male. Median follow-up was 22 months and median OS was 17 months. Median tumour size was 5 cm. Overall, 23% of patients had a positive resection margin, 44% had perineural invasion, 32% had lymphovascular invasion (LVI) and 25% had positive LNs. The median number of LNs removed was two and the median number of positive LNs was zero. The presence of LVI was associated with reduced OS (11.9 months vs. 23.1 months; P=0.023). After accounting for all other adverse tumour factors, the presence of LVI persisted as the only negative prognostic factor for OS on multivariate Cox regression.

CONCLUSIONS

In patients who had undergone resection of hilar or intrahepatic CC, the presence of LVI was strongly associated with reduced OS. Thus the finding of LVI may potentially be used as a criterion in the selection of patients for adjuvant chemotherapy.

Hilar cholangiocarcinoma: tumor depth as a predictor of outcome

BACKGROUND

The American Joint Committee on Cancer staging system for hilar cholangiocarcinoma may be inaccurate because the bile duct lacks discrete tissue boundaries.

OBJECTIVES

To examine the accuracy of the American Joint Committee on Cancer staging schemes and to determine the prognostic implications of tumor depth.

DESIGN, SETTING, AND PATIENTS

From January 1, 1987, through December 31, 2009, there were 106 patients who underwent resection of hilar cholangiocarcinoma who had pathologic slides available for re-review.

MAIN OUTCOME MEASURES

Tumor depth and overall survival.

RESULTS

Overall median survival was 19.9 months. The 6th and 7th editions of the T-classification criteria were unable to discriminate among T1, T2, and T3 lesions (P > .05 for all). Median survival was associated with the invasion depth of the tumor (≥5 mm vs <5 mm): 18 months vs 30 months (P = .01). On multivariate analysis, tumor depth remained predictive of disease-specific death (hazard ratio, 1.70; P = .03).

CONCLUSIONS

The American Joint Committee on Cancer T-classification criteria did not stratify patients with regard to prognosis. Depth of tumor invasion is a better predictor of long-term outcome.

Using the greater omental flap to cover the cut surface of the liver for prevention of delayed gastric emptying after left-sided hepatobiliary resection: a prospective randomized controlled trial

OBJECTIVE

The aim of this randomized controlled trial is to evaluate the effect on delayed gastric emptying (DGE) of using the greater omental flap to cover the cut surface of the liver after left-sided hepatobiliary resection.

METHODS

From June 2007 to December 2008, all eligible patients were randomly assigned to either the greater omental flap group (OF group) or the control group (non-OF group).

RESULTS

A total of 40 patients remained for final analysis. The incidence of DGE after left-sided hepatobiliary resection was 25%. The incidence of DGE showed no statistically significant differences between the OF group (10%) and the non-OF group (40%) (p = 0.065). The assessment of DGE using radiopaque rings revealed that changes over time in the gastric emptying ratio (GER, percentage of rings excreted from stomach) did not differ in a significant manner between the two groups. There were significant differences in changes over time in GER (p = 0.044) between the patients with and without DGE. The patients with DGE also showed higher GER at 5 h (p = 0.042) and at 6 h (p = 0.034) than those without DGE.

CONCLUSIONS

Using the greater omental flap to cover the cut surface of the liver may reduce the incidence of DGE after left-sided hepatobiliary resection. Assessment using radiopaque markers may be useful to evaluate DGE.

Surgical strategy for bile duct cancer: Advances and current limitations

The aim of this review is to describe recent advances and topics in the surgical management of bile duct cancer. Radical resection with a microscopically negative margin (R0) is the only way to cure cholangiocarcinoma and is associated with marked survival advantages compared to margin-positive resections. Complete resection of the tumor is the surgeon's ultimate aim, and several advances in the surgical treatment for bile duct cancer have been made within the last two decades. Multidetector row computed tomography has emerged as an indispensable diagnostic modality for the precise preoperative evaluation of bile duct cancer, in terms of both longitudinal and vertical tumor invasion. Many meticulous operative procedures have been established, especially extended hepatectomy for hilar cholangiocarcinoma, to achieve a negative resection margin, which is the only prognostic factor under the control of the surgeon. A complete caudate lobectomy and resection of the inferior part of Couinaud's segment IV coupled with right or left hemihepatectomy has become the standard surgical procedure for hilar cholangiocarcinoma, and pylorus-preserving pancreaticoduodenectomy is the first choice for distal bile duct cancer. Limited resection for middle bile duct cancer is indicated for only strictly selected cases. Preoperative treatments including biliary drainage and portal vein embolization are also indicated for only selected patients, especially jaundiced patients anticipating major hepatectomy. Liver transplantation seems ideal for complete resection of bile duct cancer, but the high recurrence rate and decreased patient survival after liver transplant preclude it from being considered standard treatment. Adjuvant chemotherapy and radiotherapy have a potentially crucial role in prolonging survival and controlling local recurrence, but no definite regimen has been established to date. Further evidence is needed to fully define the role of liver transplantation and adjuvant chemo-radiotherapy.