Radical surgery for hilar cholangiocarcinoma

Development of the liver resection transfusion (LiReT) score to assess the requirement for blood transfusion during open liver surgery

BACKGROUND

Liver resection involves significant perioperative bleeding and blood transfusions, which may worsen outcomes. Blood products are scarce, and excessive preoperative cross-matching can deplete the blood supply. This study aimed to develop a clinical prediction score to assess the need for perioperative blood transfusions during liver resection.

METHODS

We conducted a retrospective cohort study using data from patients who underwent liver resections between 2006 and 2021. Independent predictors and a scoring system were analyzed using multivariable logistic regression. The model's effectiveness was assessed by the area under the ROC curve (AuROC) and calibration plots, with internal validation.

RESULT

Among 1021 patients, 456 (44.7%) required perioperative blood transfusions. Eight predictors were identified: ASA classification >2, preoperative anemia, platelet count <100 × 109/L, albumin <3.5 g/dL, total bilirubin >1.2 mg/dL, GFR <60 ml/min/1.73 m², maximum tumor diameter ≥5 cm, and major liver resection. The LiReT score categorized patients into low, moderate, and high-risk groups and showed good discriminative ability with an AuROC of 0.808 and good calibration.

CONCLUSION

The LiReT score, with its good predictive accuracy, can guide clinicians in assessing perioperative blood transfusion risk, optimizing cross-matching and resource utilization, and facilitating patient blood management strategies during liver resection.

Influence of Perineural (Pn), Lymphangio (L) and Vascular (V) Invasion on Survival after Resection of Perihilar Cholangiocarcinoma

INTRODUCTION

Perihilar cholangiocarcinoma is a rare malignancy of the biliary tract, for which surgery remains the treatment of choice. However, even after radical resection, the prognosis is poor. In addition to tumor size, depth of invasion and nodal/metastatic status, the TNM classification includes additional parameters such as perineural (Pn), lymphangio (L) and vascular (V) invasion. The prognostic impact of these factors is not yet fully understood. The aim of this study was to investigate the influence of these parameters on overall survival after resection of perihilar cholangiocarcinoma.

MATERIAL AND METHODS

Data from all patients who underwent surgical exploration for perihilar cholangiocarcinoma between January 2013 and December 2023 were included into an institutional database. The impact of perineural, lymphangio and vascular invasion on overall survival was analyzed.

RESULTS

Over the 11-year period, a total of 214 patients underwent surgical exploration for perihilar cholangiocarcinoma. Curative intended resection was possible in 168 patients (78.5%). Perineural invasion, lymphangio invasion and vascular invasion were present in 79.2%, in 17.3% and in 14.3% of patients, respectively. Cross tabulation revealed a significant association between the presence of L1 and V1 (p = 0.006). There was also a significant association of Pn1, L1, and V1 with R-status (p = 0.010; p = 0.006 and p ≤ 0.001). While V1 was associated with significantly worse overall survival across the entire cohort, Pn1 alone showed only a tendency towards worse overall survival without reaching statistical significance. In Bismuth type IV, both L1 and V1, but not Pn1, were significantly associated with worse overall survival (p = 0.001; p = 0.017 and p = 0.065).

CONCLUSIONS

Perineural invasion is very common in perihilar cholangiocarcinoma. Although Pn1 was associated with a tendency toward worse survival, it did not reach statistical significance. In contrast, vascular invasion significantly worsened overall survival in the entire cohort, and lymphangio invasion was linked to worse overall survival in Bismuth type IV tumors. The combination of perineural invasion with positivity of more than one additional factor (either L or V) was also associated with worse overall survival. In patients with Bismuth type IV, these pathological markers appeared to have even greater prognostic relevance.

Preoperative predictors for non-resectability in perihilar cholangiocarcinoma

INTRODUCTION

Explorative laparotomy without subsequent curative-intent liver resection remains a major clinical problem in the treatment of perihilar cholangiocarcinoma (pCCA). Thus, we aimed to identify preoperative risk factors for non-resectability of pCCA patients.

MATERIAL AND METHODS

Patients undergoing surgical exploration between 2010 and 2022 were eligible for the analysis. Separate binary logistic regressions analyses were used to determine risk factors for non-resectability after explorative laparotomy due to technical (tumor extent, vessel infiltration) and oncological (peritoneal carcinomatosis, distant nodal or liver metastases)/liver function reasons.

RESULTS

This monocentric cohort comprised 318 patients with 209 (65.7%) being surgically resected and 109 (34.3%) being surgically explored [explorative laparotomy: 87 (27.4%), laparoscopic exploration: 22 (6.9%)]. The median age in the cohort was 69 years (range 60-75) and a majority had significant comorbidities with ASA-Score ≥ 3 (202/318, 63.5%). Statistically significant (p < 0.05) risk factors for non-resectability were age above 70 years (HR = 3.76, p = 0.003), portal vein embolization (PVE, HR = 5.73, p = 0.007), and arterial infiltration > 180° (HR = 8.05 p < 0.001) for technical non-resectability and PVE (HR = 4.67, p = 0.018), arterial infiltration > 180° (HR = 3.24, p = 0.015), and elevated CA 19-9 (HR = 3.2, p = 0.009) for oncological/liver-functional non-resectability.

CONCLUSION

Advanced age, PVE, arterial infiltration, and elevated CA19-9 are major risk factors for non-resectability in pCCA. Preoperative assessment of those factors is crucial for better therapeutical pathways. Diagnostic laparoscopy, especially in high-risk situations, should be used to reduce the amount of explorative laparotomies without subsequent liver resection.

Should more aggressive surgical resection be considered in the treatment for Bismuth types I and II hilar cholangiocarcinoma? A meta-analysis

Evidence regarding the optical surgical extent for Bismuth type I/II HCCA is lacking. we aims to evaluate the optimal surgical methods for Bismuth type I/II HCCA. Studies comparing bile duct resection (BDR) and BDR combined with liver resection (BDR + LR) for all types of HCCA patients were searched for analyses, and 14 studies were finally included. The main outcomes were the R0 resection rate and overall survival (OS). For all types of HCCA patents, BDR + LR resulted with higher R0 resection rates when comparing with BDR only (RR = 0.70, 95%CI, 0.63-0.78), and patients with R0 resections had eight times longer median survival and more long-time survival outcomes (3 and 5 year OS) comparing to those with non-R0 resections. Bismuth I/II HCCA patients also showed longer median survival and 3-year OS after R0 resections (P = 0.04). Moreover, there was no significant difference in 3-year OS between BDR and BDR + LR (P = 0.89) and we additionally found BDR resulted in less mortality or morbidity rates. In Europe and US, they resulted the R0 resection rates could be comparable between BDR and BDR + LR (P = 0.18), and Bismuth type I HCCA accounted for 75.8%, while in Asia, BDR + LR still resulted with higher R0 resection rates (P < 0.0001) and the Bismuth type I HCCA accounted for only 40.3%. The surgical approaches may not directly impact patient prognosis, patients with R0 resections are usually associated with improved survival outcomes; for selected Bismuth type I/II HCCA, BDR may be an acceptable option with regard to lower morbidity and comparable R0 resection rate comparing with BDR + LR.

Comparative study on left-sided versus right-sided hepatectomy for resectable peri-hilar cholangiocarcinoma: a systematic review and meta-analysis

BACKGROUND

Peri-hilar cholangiocarcinoma (pCCA) is a unique entity, and radical surgery provides the only chance for cure and long-term survival. But it is still under debate which surgical strategy (i.e., left-sided hepatectomy, LH or right-sided hepatectomy, RH) should be followed and benefitted.

METHODS

We performed a systematic review and meta-analysis to analyze the clinical outcomes and prognostic value of LH versus RH for resectable pCCA. This study followed the PRISMA and AMSTAR guidelines.

RESULTS

A total of 14 cohort studies include 1072 patients in the meta-analysis. The results showed no statistical difference between the two groups in terms of overall survival (OS) and disease-free survival (DFS). But compared to the LH group, the RH group exhibited more employment of preoperative portal vein embolization (PVE), higher rate of overall complications, post-hepatectomy liver failure (PHLF), and perioperative mortality, while LH was associated with higher frequency of arterial resection/reconstruction, longer operative time, and more postoperative bile leakage. There was no statistical difference between the two groups in terms of preoperative biliary drainage, R0 resection rate, portal vein resection, intraoperative bleeding, and intraoperative blood transfusion rate.

CONCLUSIONS

According to our meta-analyses, LH and RH have comparable oncological effects on curative resection for pCCA patients. Although LH is not inferior to RH in DFS and OS, it requires more arterial reconstruction which is technically demanding and should be performed by experienced surgeons in high-volume centers. Selectin of surgical strategy between LH and RH should be based on not only tumor location (Bismuth classification) but also vascular involvement and future liver remnant (FLR).

Oncological outcome of proximal and middle extrahepatic bile duct cancer according to surgical extent (Is hilar resection oncologically acceptable in proximal and middle extrahepatic bile duct cancer?)

BACKGROUND

For proximal to middle bile duct cancer, it is controversial whether bile duct resection alone is sufficient, or whether hepatic or pancreatic resection should be accompanied by initial planning. This study aimed to determine the optimal surgical extent based on oncological outcomes in patients with proximal to middle bile duct cancer.

METHODS

Patients who underwent surgery for proximal to middle extrahepatic bile duct cancer, hilar resection, or combined resection of other organs were included. Clinicopathological characteristics and survival analyses were compared according to operation type.

RESULTS

Among 156 patients in total, R0 rate was 56.7% for hilar resection and 82.7% for other organ resection. Although hilar resection was associated with shorter hospital stay and fewer overall complications, operation type did not affect overall survival (p = 0.259) and disease-free-survival (p = 0.774). Overall survival differed according to R status (5YSR 49.8 vs. 27.1%; p = 0.012).

CONCLUSION

In proximal to middle extrahepatic bile duct cancer, surgery should be tailored to achieve R0 resection according to the extent of the disease rather than uniformly resecting extensively with other organ resections. Hilar resection could be selected if R0 resection is feasible, considering the lower morbidity with similar long-term survival.

The prognostic role of tumor-associated unilateral portal vein occlusion in perihilar cholangiocarcinoma

BACKGROUND

While a certain degree of tumor infiltration of the portal vein is common in patients with perihilar cholangiocarcinoma (pCCA) scheduled for surgery, complete tumor-associated portal vein occlusion (PVO) is less frequently observed. Here, we analyzed the impact of PVO on perioperative and oncological outcomes in pCCA patients.

METHODS

Between 2010 and 2019, 127 patients with pCCA underwent surgery in curative intent at our department of which 17.3% (22/127) presented with PVO. Extensive group comparisons were conducted and the association of cancer-specific (CSS) and disease-free survival (DFS) with PVO and other clinico-pathological characteristics were assessed using Cox regression models.

RESULTS

Patients without PVO showed a median CSS of 65 months (3-year-CSS = 64%, 5-year-CSS = 53%) compared to 31 months (3-year-CSS = 43%, 5-year-CSS = 17%) in patients with PVO (p = 0.025 log rank). Patients with PVO did also display significant perioperative mortality (22.7%, 5/22) compared to patients without PVO (14.3%, 15/105, p = 0.323). Further, PVO (CSS: HR = 5.25, p = 0.001; DFS: HR = 5.53, p = 0.001) was identified as independent predictors of oncological outcome.

CONCLUSIONS

PVO has been identified as an important prognostic marker playing a role in inferior oncological outcome in patients with pCCA. As PVO is also associated with notable perioperative mortality, surgical therapy should be considered carefully in pCCA patients.

The prognostic role of in-hospital transfusion of fresh frozen plasma in patients with cholangiocarcinoma undergoing curative-intent liver surgery

INTRODUCTION

Major hepatectomy for perihilar and intrahepatic cholangiocarcinoma (CCA) is often associated with a significant intraoperative blood loss and the requirement for perioperative transfusion of blood products. The aim of this study was to investigate the oncological impact of fresh frozen plasma (FFP) transfusion during hospitalization in patients undergoing hepatectomy for CCA as adverse effects have been described in other malignancies.

MATERIAL AND METHODS

Patients undergoing hepatectomy for CCA from 2010 to 2019 at a single institution were eligible for this study. Survival analysis was carried out according to Kaplan-Meier and the associations of cancer-specific (CSS) and recurrence-free survival (RFS) with in-hospital application of FFP and other clinico-pathological characteristics were assessed using Cox regression models. Perioperatively deceased patients were excluded from the analysis.

RESULTS

A total of 219 CCA patients were included in this survival analysis of which 53.0% (116/219) received FFP during hospitalization. Patients receiving in-hospital FFP showed a median CCS of 33 months (3-year-CSS = 46%, 5-year-CSS = 29%) compared to 83 months (3-year-CSS = 55%, 5-year-CSS = 53%) in patients who did not receive in-hospital FFP (p = 0.006 log rank). Further, in-hospital FFP was identified as an independent predictor of oncological outcome in multivariable analysis (CSS: HR = 1.71, p = 0.016; RFS: HR = 1.89, p = 0.003).

CONCLUSION

In a large European cohort of patients, in-hospital transfusion of FFP was identified as a novel independent prognostic marker in CCA patients undergoing curative-intent liver surgery. A restrictive transfusion policy is therefore recommended to improve long-term outcome in these patients.

Nerve Fibers in the Tumor Microenvironment as a Novel Biomarker for Oncological Outcome in Patients Undergoing Surgery for Perihilar Cholangiocarcinoma

INTRODUCTION

Perihilar cholangiocarcinoma (pCCA) is a biliary tract cancer with a dismal prognosis, with surgery being the only chance of cure. A characteristic aggressive biological feature of pCCA is perineural growth which is defined by the invasion of cancer cells to nerves and nerve fibers. Recently, nerve fiber density (NFD) was linked to oncological outcomes in various malignancies; however, its prognostic role in pCCA remains to be elucidated.

MATERIALS AND METHODS

Data of 101 pCCA patients who underwent curative-intent surgery between 2010 and 2019 were included in this study. Extensive group comparisons between patients with high and low NFD were carried out, and the association of cancer-specific survival (CSS) and recurrence-free survival with NFD and other clinicopathological characteristics was assessed using univariate and multivariable cox regression models.

RESULTS

Patients with high NFD showed a median CSS of 90 months (95% CI: 48-132, 3-year CSS = 77%, 5-year CSS = 72%) compared to 33 months (95% CI: 19-47, 3-year CSS = 46%, 5-year CSS = 32%) in patients with low NFD (p = 0.006 log rank). Further, N1 category (HR = 2.84, p = 0.001) and high NFD (HR = 0.41, p = 0.024) were identified as independent predictors of CSS in multivariable analysis. Patients with high NFD and negative lymph nodes showed a median CSS of 90 months (3-year CSS = 88%, 5-year CSS = 80%), while patients with either positive lymph nodes or low NFD displayed a median CSS of 51 months (3-year CSS = 59%, 5-year CSS = 45%) and patients with both positive lymph nodes and low NFD a median CSS of 24 months (3-year CSS = 26%, 5-year CSS = 16%, p = 0.001 log rank).

CONCLUSION

NFD has been identified as an important novel prognostic biomarker in pCCA patients. NFD alone and in combination with nodal status in particular allows to stratify pCCA patients based on their risk for inferior oncological outcomes after curative-intent surgery.

A tailored approach in lymph node-positive perihilar cholangiocarcinoma

Purpose

Extended right hepatectomy is associated with wide surgical margins in PHC and often favored for oncological considerations. However, it remains uncertain whether established surgical principles also apply to the subgroup of node-positive patients. The aim of the present study was to define a tailored surgical approach for patients with perihilar cholangiocarcinoma (PHC) and lymph node metastases.

Methods

We reviewed the course of all consecutive patients undergoing major hepatectomy for PHC between 2005 and 2015 at the Department of Surgery, Charité – Universitätsmedizin Berlin.

Results

Two hundred and thirty-one patients underwent major hepatectomy for PHC with 1-, 3-, and 5-year overall (OS) and disease-free survival (DFS) rates of 72%, 48%, and 36%, and 60%, 22%, and 12%, respectively. In lymph node-positive patients (n = 109, 47%), extended left hepatectomy was associated with improved OS and DFS, respectively, when compared to extended right hepatectomy (p = 0.008 and p = 0.003). Interestingly, OS and DFS did not differ between R0 and R1 resections in those patients (both p = ns). Patients undergoing extended left hepatectomy were more likely to receive adjuvant chemotherapy (p = 0.022). This is of note as adjuvant chemotherapy, besides grading (p = 0.041), was the only independent prognostic factor in node-positive patients (p=0.002).

Conclusion

Patients with node-positive PHC might benefit from less aggressive approaches being associated with lower morbidity and a higher chance for adjuvant chemotherapy. Lymph node sampling might help to guide patients to the appropriate surgical approach according to their lymph node status.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-021-02154-4.

Bacterial bile duct colonization in perihilar cholangiocarcinoma and its clinical significance

Abdominal infections including cholangitis represent a major problem in patients with perihilar cholangiocarcinoma (pCCA). Thus, we investigated bacterial colonization of the bile ducts and determined its impact on postoperative outcome focusing on abdominal infections. A cohort of 95 pCCA patients who underwent surgery between 2010 and 2019 with available intraoperative microbial bile cultures were analyzed regarding bile duct colonization and postoperative abdominal infection by group comparisons and logistic regressions. 84.2% (80/95) showed bacterial colonization of the bile ducts and 54.7% (52/95) developed postoperative abdominal infections. Enterococcus faecalis (38.8%, 31/80), Enterococcus faecium (32.5%, 26/80), Enterobacter cloacae (16.3%, 13/80) and Escherichia coli (11.3%, 9/80) were the most common bacteria colonizing the bile ducts and Enterococcus faecium (71.2%, 37/52), Enterococcus faecalis (30.8%, 16/52), Enterobacter cloacae (25.0%, 13/52) and Escherichia coli (19.2%, 10/52) the most common causes of postoperative abdominal infection. Further, reduced susceptibility to perioperative antibiotic prophylaxis (OR = 10.10, p = .007) was identified as independent predictor of postoperative abdominal infection. Bacterial colonization is common in pCCA patients and reduced susceptibility of the bacteria to the intraoperative antibiotic prophylaxis is an independent predictor of postoperative abdominal infections. Adapting antibiotic prophylaxis might therefore have the potential to improve surgical outcome pCCA patients.

Left- versus right-sided hepatectomy with hilar en-bloc resection in perihilar cholangiocarcinoma

BACKGROUND

Major liver resections with portal vein resection (PVR) have emerged as the preferred treatment for patients with perihilar cholangiocarcinoma (pCCA). Whether the resection of the liver should be preferably performed as left- (LH) or right-sided hepatectomy (RH) with or without hilar en-bloc technique is still subject of ongoing debate.

METHODS

Between 2011 and 2016, 91 patients with pCCA underwent surgery in curative intent at our institution. Perioperative, pathological and survival data from all consecutive patients undergoing hilar en-bloc resection for pCCA were analyzed retrospectively. Patients undergoing hepatoduodenectomy (n = 8) or ALPPS (Associating liver partition and portal vein ligation for staged hepatectomy) (n = 2) were excluded from the analysis.

RESULTS

Tumor grading, microvascular invasion, lymphovascular invasion, N-category, T-category, R-status and UICC-tumor staging were similar in the RH (n = 45) and LH (n = 36) groups. Perioperative morbidity and mortality were higher after RH compared to LH (mortality: 15.6% (7/45) vs. 8.3% (3/36) p = 0.003). Three-year (62% vs. 51%) and the 5-year OS (30% vs. 46%) were comparable between LH and RH groups respectively (p = 0.519, log rank).

CONCLUSIONS

The present study supports the concept of surgically aggressive therapy in pCCA. LH and RH hilar en-bloc resection demonstrate a comparable long-term survival, suggesting that LH hilar en-bloc resections are feasible and safe in high-volume centers.

Right-side versus left-side hepatectomy for the treatment of hilar cholangiocarcinoma: a comparative study

Background

Radical resection is the only curative treatment for patients with hilar cholangiocarcinoma. While left-side hepatectomy (LH) may have an oncological disadvantage over right-side hepatectomy (RH) owing to the contiguous anatomical relationship between right hepatic inflow and biliary confluence, a small future liver remnant after RH could cause worse surgical morbidity and mortality. We retrospectively compared surgical morbidity and long-term outcome between RH and LH to determine the optimal surgical strategy for the treatment of hilar cholangiocarcinoma.

Methods

This study considered 83 patients who underwent surgical resection for hilar cholangiocarcinoma between 2010 and 2017. Among them, 57 patients undergoing curative-intent surgery including liver resection were enrolled for analysis—33 in the RH group and 27 in the LH group. Prospectively collected clinicopathologic characteristics, perioperative outcomes, and long-term survival were evaluated.

Results

Portal vein embolization was more frequently performed in the RH group than in the LH group (18.2% vs. 0%, P = 0.034). The proportion of R0 resection was comparable in both groups (75.8% vs. 75.0%, P = 0.948). The 5-year overall and recurrence-free survival rates did not differ between the groups (37.7% vs. 41.9%, P = 0.500, and 26.3% vs. 33.9%, P = 0.580, respectively). The side of liver resection did not affect long-term survival. In multivariate analysis, transfusion (odds ratio, 3.12 [1.42–6.87], P = 0.005) and post-hepatectomy liver failure (≥ grade B, 4.62 [1.86–11.49], P = 0.001) were independent risk factors for overall survival.

Conclusions

We recommend deciding the side of liver resection according to the possibility of achieving radical resection considering the anatomical differences between RH and LH.

A 17 years retrospective study on multiple metal stents for complex malignant hilar biliary strictures: Survival, stents patency and outcomes of re-interventions for occluded metal stents

BACKGROUND

Endoscopic placement of SEMSs for malignant hilar biliary strictures (MHBS) is well-established palliative treatment for inoperable patients. Objectives of this study were evaluation of survival and stents patency after placement of multiple SEMS for palliation of complex MHBS.

METHODS

Retrospective review of patients with MHBS that underwent ERCP with insertion of multiple SEMSs for palliation. Survival-associated factors and stents patency were analyzed by Cox multivariate analysis.

RESULTS

Between January 1998 and January 2015, 740 patients with nonoperable MHBS that underwent ERCP were identified and only 18.2% of these received multiple SEMSs. Complications were observed in 7.5% of the patients with no procedure-related mortality. Palliative therapies (chemotherapy, external beam radiotherapy and high dose rate brachytherapy) were done in some patients, and outcomes were evaluated. Overall mean survival of the 134 patients was 323 days. Of these, 59% did not had stents malfunction while 41% patients had episodes of SEMSs malfunction and mean survival after re-interventions was 502.9 days. Survival was not influenced by type of tumor, sex or age.

CONCLUSIONS

Endoscopic multiple SEMSs placement is safe and effective in patients with complex MHBS. Survival is independent from the type and complexity of MHBS while is prolonged in patients undergoing HDR brachytherapy. Prompt recognition of SEMSs malfunction is fundamental for survival.

Left Hepatectomy with Combined Resection and Reconstruction of Right Hepatic Artery for Bismuth Type I and II Perihilar Cholangiocarcinoma

BACKGROUND

Right hepatectomy with caudate lobectomy (RHx) is considered an appropriate procedure for Bismuth type I/II perihilar cholangiocarcinoma in terms of its anatomical and oncological aspect. However, validity of left hepatectomy with caudate lobectomy (LHx) concomitant with arterial resection and reconstruction (AR) is not fully evaluated.

METHODS

The patients who underwent surgical resection for Bismuth type I/II perihilar cholangiocarcinoma between 2002 and 2013 were studied. The standard procedure for Bismuth type I/II cholangiocarcinoma in the institute was RHx, while in patients who had insufficient functional reserve of the left liver, LHx was selected, irrespective of the necessity of AR. The clinicopathologic and perioperative outcomes after LHx + AR were compared with those after RHx.

RESULTS

The surgical procedures comprised LHx + AR in 12 and RHx in 24. The left liver volume and left liver functional reserve were significantly lower with LHx + AR than with RHx (left liver volume: 28.0 vs. 33.7%, p = 0.026; estimated indocyanine green clearance of the left liver: 0.036 vs. 0.046, p < 0.001). The rate of surgical morbidity was almost identical between the two procedures. No arterial reconstruction-related complications occurred. The overall 3- and 5-year survival rates and median survival time were 66.7%, 41.7% and 44 months for LHx + AR and 70.8%, 49.0% and 57 months for RHx (p = 0.640).

CONCLUSION

LHx + AR for Bismuth type I/II perihilar cholangiocarcinoma is considered to be a valid alternative to RHx in patients with an insufficient left liver functional reserve.

The prognostic role of lymphovascular invasion and lymph node metastasis in perihilar and intrahepatic cholangiocarcinoma

INTRODUCTION

Cholangiocellular carcinoma (CCA) is an aggressive malignancy with a dismal prognosis. Among curative treatment options for CCA, radical surgical resection with extrahepatic bile duct resection, hepatectomy and en-bloc lymphadenectomy are considered the mainstay of curative therapy. Here, we aimed to identify prognostic markers of clinical outcome in CCA-patients who underwent surgical resection in curative intent.

MATERIAL AND METHODS

Between 2011 and 2016, 162 patients with CCA (perihilar CCA (pCCA): n = 91, intrahepatic CCA (iCCA): n = 71) underwent surgery in curative intent at our institution. Preoperative characteristics, perioperative data and oncological follow-up were obtained from a prospectively managed institutional database. The associations of overall- (OS) and disease-free-survival (DFS) with clinico-pathological characteristics were assessed using univariate and multivariable cox regression analyses.

RESULTS

The median OS and DFS were 38 and 36 months for pCCA and 25 and 13 months for iCCA, respectively. Lymphovascular invasion (LVI) and lymph node metastasis as well as surgical complications as assessed by the comprehensive complication index (CCI) and tumor grading were independently associated with OS for the pCCA (LVI; RR = 2.36, p = 0.028; CCI; RR = 1.04, p < 0.001) and iCCA cohorts (N-category; RR = 3.21, p = 0.040; tumor grading; RR = 3.75, p = 0.013; CCI, RR = 4.49, p = 0.010), respectively. No other clinical variable including R0-status and Bismuth classification was associated with OS.

CONCLUSION

Major liver resections for CCA are feasible and safe in experienced high-volume centers. Lymph node metastasis and LVI are associated with adverse clinical outcome, supporting the role of systematic lymphadenectomy. The assessment of LVI may be useful in identifying high-risk patients for adjuvant treatment strategies.

Implementation of comprehensive rehabilitation therapy in postoperative care of patients with cholangiocarcinoma and its impact on patients' quality of life

Implementation of comprehensive rehabilitation therapy in postoperative care of patients with cholangiocarcinoma was studied to explore its impact on patients' quality of life. Two hundred and nineteen patients with cholangiocarcinoma who underwent surgery in Yidu Central Hospital of Weifang from April 2014 to June 2017 were selected as study subjects. Of these patients, 116 received comprehensive rehabilitation therapy, in addition to chemotherapy, after surgery and were assigned to the experimental group. The remaining 103 patients received routine treatment after surgery and were assigned to the control group. Under the guidance of experts, patients in the experimental group carried out multiple comprehensive rehabilitation activities, such as exercises on general physical function, adjustment of psychological state and recovery of social family function. The outcome after 1 month of treatment was evaluated for the two groups according to the RECIST 1.1 guidelines. Nutritional status of patients before surgery, at 1 day and at 1 month after surgery was measured according to the Nutritional Risk Screening endorsed by the European Society for Clinical Nutrition and Metabolism (ESPEN). The quality of life at 1 month after surgery was assessed based on the QLQ-C30 quality of life questionnaire. The negative emotions that patients experienced at 1 month after surgery were assessed using the self-rating anxiety scale (SAS) and the self-rating depression scale (SDS). The response rate in the experimental group was 76.72%, which was significantly higher than 46.60% in the control group (P<0.05). At 1 month after surgery, the nutritional status and quality of life, as well as SAS/SDS scores, were significantly better in the experimental group than in the control group, and the differences were statistically significant (P<0.05). In clinical anticancer treatment, synergistic implementation of comprehensive rehabilitation therapy can improve patients' psychological health status, nutritional status and the overall quality of life, and reduce the impact of negative emotions on the physical state.

Single-incision laparoscopic surgery portal vein embolisation before extended hepatectomy

Objective:

Portal vein embolisation (PVE) represents the standard procedure for augmentation of the contralateral lobe before extended right hepatectomy. However, possible limitations for the percutaneous transhepatic approach exist, for example, large tumours of the right lobe. Here, we present our experiences with single-incision laparoscopic surgery-PVE (SILS-PVE) as an alternative approach for settings where percutaneous routes are technically not feasible.

Methods:

A small umbilical incision is performed, and a GelPOINT Mini Advanced Access Platform (Santa Margarida, CA, USA) is placed. Staging laparoscopy is performed routinely followed by identification of an appropriate ileal segment, which is subsequently exteriorized through the small umbilical incision. A peripheral mesenteric vein is encircled and cannulated to access right portal vein branches. After sufficient embolisation of the right lobe, the peripheral vein is ligated, the single port is extracted and the umbilical wound is closed.

Results:

SILS-PVE was successfully applied in 10 patients (median age 60.5 years) between 12/2015 and 03/2018. The technique was indicated due to extensive tumours in the right lobe (n = 8), extensive hydatid cyst (n = 1) and during SILS right hemicolectomy in Stage IV colon cancer (n = 1). Mean operative time was 184 min (range 116–315). Patients were discharged on post-operative day 4 (range 2–9). Augmentation of the future liver remnant volume was assessed by computed tomography-volumetry 3–4 weeks after SILS-PVE and showed a mean relative increase of 64.95%, future remnant liver function showed a mean increase of 120.77%.

Conclusion:

The proposed SILS-PVE represents a technically simple and safe alternative to standard percutaneous transhepatic approaches. Perioperative risks can be minimised by minimally-invasive surgery, which is of explicit importance in multimodal approaches before major hepatectomy.

Hilar en bloc resection for hilar cholangiocarcinoma in patients with limited liver capacities-preserving parts of liver segment 4

Background

A right trisectionectomy with portal vein resection represents the conventional approach for hilar cholangiocarcinoma. Here, we present a technical modification of hilar en bloc resection in order to increase the remnant volume by partially preserving liver segment 4.

Methods

The caudal parenchymal dissection line starts centrally between the left lateral and left medial segments. Cranially, the resection line switches to the right towards Cantlie's line and turns again upwards perpendicularly. Hence, segment 4a and subtotal segment 4b are partially preserved by this novel technique. The left hepatic duct is dissected at the segmental ramification and reconstruction is performed as a single hepaticojejunostomy. The feasibility of the novel parenchyma-sparing approach for hilar cholangiocarcinoma was proven in a case series and medical records were reviewed retrospectively.

Results

Ten patients (6 male, 4 female) underwent segment 4 partially preserving right trisectionectomy for hilar cholangiocarcinoma. Estimated future liver remnant volume was significantly increased (FLRV 38.3%), when compared to standard right trisectionectomy (FLRV 23.9%; p < 0.01). Three of 10 liver resections were associated with major surgical complications (≥IIIb; n = 3); categorized according to the Dindo-Clavien classification. No patient died due to complications associated with postoperatively impaired liver function. Tumor-free margins could be achieved in 8 patients while median overall survival and disease-free survival were 547 and 367 days, respectively.

Conclusion

This novel parenchyma-sparing modification of hilar en bloc resection by partially preserving segment 4 allows to safely increase the remnant liver volume without neglecting principles of local radicality.

Impact of Preoperative Three-Dimensional Computed Tomography Cholangiography on Postoperative Resection Margin Status in Patients Operated due to Hilar Cholangiocarcinoma

INTRODUCTION

The purpose of this study was to analyse the value of 3-dimensional computed tomography cholangiography (3D-ERC) compared to conventional retrograde cholangiography in the preoperative diagnosis of hilar cholangiocarcinoma (HC) with special regard to the resection margin status (R0/R1).

PATIENTS AND METHODS

All hepatic resections performed between January 2011 and November 2013 in patients with HC at the Department of General, Visceral and Transplant Surgery of the RWTH Aachen University Hospital were analysed. All patients underwent an ERC and contrast-enhanced multiphase CT scan or a 3D-ERC.

RESULTS

The patient collective was divided into two groups (group ERC: n = 17 and group 3D-ERC: n = 16). There were no statistically significant differences between the two groups with regard to patient characteristics or intraoperative data. Curative liver resection with R0 status was reached in 88% of patients in group ERC and 87% of patients in group 3D-ERC (p = 1.00). We could not observe any differences with regard to postoperative complications, hospital stay, and mortality rate between both groups.

CONCLUSION

Based on our findings, preoperative imaging with 3D-ERC has no benefit for operative planning and R0 resection status. It cannot replace the exploration by an experienced surgeon in a centre for hepatobiliary surgery.

Cholangiocarcinoma

Biliary tract cancer accounts for <1% of all cancers and affects chiefly an elderly population, with predominance in men. We distinguish cholangiocarcinoma (intrahepatic, hilar and distal) and gallbladder cancer, with different pathogenesis and prognosis. The treatment is based on surgery (whenever possible), radiotherapy in selected cases, and chemotherapy. The standard cytotoxic treatment for advanced/metastatic disease is represented by the combination of gemcitabine and cisplatin, whereas fluoropyrimidines are generally administered in second line setting. At the present time, no biologic drug demonstrated a clear efficacy in this cancer, although the molecular characterisation could provide a promising basis for experimental treatments. A good supportive care and an early palliative care are warranted in most patients and should be delivered as a part of a global approach.

Extended right hepatectomy with caudate lobe resection using the hilar "en bloc" resection technique with a modified hanging maneuver

The hanging liver maneuver is a useful technique to guide the transection of liver parenchyma by lifting a tape passed between the anterior surface of the inferior vena cava and the liver. Modified hanging liver maneuvers have been described in different types of liver resection. Surgical resection of hilar cholangiocarcinoma can involve the portal vein and the caudate lobe for margin clearance. However, hilar dissection and resection of the caudate lobe can be a challenging during the hanging maneuver once the tape is positioned. Herein, we describe a modified hanging liver maneuver for a hilar "en bloc" extended right hepatectomy with portal vein resection for the treatment of hilar cholangiocarcinoma including the caudate lobe. J. Surg. Oncol. 2016;113:427-431. © 2016 Wiley Periodicals, Inc.

Prognostic significance of macrophage invasion in hilar cholangiocarcinoma

Background

Tumor-associated macrophages (TAMs) promote tumor progression and have an effect on survival in human cancer. However, little is known regarding their influence on tumor progression and prognosis in human hilar cholangiocarcinoma.

Methods

We analyzed surgically resected tumor specimens of hilar cholangiocarcinoma (n = 47) for distribution and localization of TAMs, as defined by expression of CD68. Abundance of TAMs was correlated with clinicopathologic characteristics, tumor recurrence and patients’ survival. Statistical analysis was performed using SPSS software.

Results

Patients with high density of TAMs in tumor invasive front (TIF) showed significantly higher local and overall tumor recurrence (both ρ < 0.05). Furthermore, high density of TAMs was associated with decreased overall (one-year 83.6 % vs. 75.1 %; three-year 61.3 % vs. 42.4 %; both ρ < 0.05) and recurrence-free survival (one-year 93.9 % vs. 57.4 %; three-year 59.8 % vs. 26.2 %; both ρ < 0.05). TAMs in TIF and tumor recurrence, were confirmed as the only independent prognostic variables in the multivariate survival analysis (all ρ < 0.05).

Conclusions

Overall survival and recurrence free survival of patients with hilar cholangiocarcinoma significantly improved in patients with low levels of TAMs in the area of TIF, when compared to those with a high density of TAMs. These observations suggest their utilization as valuable prognostic markers in routine histopathologic evaluation, and might indicate future therapeutic approaches by targeting TAMs.

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.

Imaging-based evaluation of liver function: comparison of ⁹⁹mTc-mebrofenin hepatobiliary scintigraphy and Gd-EOB-DTPA-enhanced MRI

OBJECTIVES

To compare Gd-EOB-enhanced MRI and (99m)Tc-mebrofenin hepatobiliary scintigraphy (HBS) as imaging-based liver function tests for separate evaluation of right (RLL) and left liver lobe (LLL) function.

METHODS

Fourteen patients underwent Gd-EOB-enhanced MRI and (99m)Tc-mebrofenin HBS after portal vein embolization within 24 h. Relative enhancement (RE) and hepatic uptake index (HUI) were determined from MRI; and T max, T 1/2 and mebrofenin uptake were determined from HBS, all values separately for RLL and LLL.

RESULTS

Mebrofenin uptake correlated significantly with HUI and RE for both liver lobes. There was strong correlation of mebrofenin uptake with HUI for RLL (r (2) = 0.802, p = 0.001) and RE for LLL (r (2) = 0.704, p = 0.005) and moderate correlation with HUI for LLL (r (2) = 0.560, p = 0.037) and RE for RLL (r (2) = 0.620, p = 0.018). Correlating the percentage share of RLL function derived from MRI (with HUI) with the percentage of RLL function derived from mebrofenin uptake revealed a strong correlation (r (2) = 0.775, p = 0.002).

CONCLUSIONS

Both RE and HUI correlate with mebrofenin uptake in HBS. The results suggest that Gd-EOB-enhanced MRI and (99m)Tc-mebrofenin HBS may equally be used to separately determine right and left liver lobe function.

KEY POINTS

• Information about liver function can be acquired with routine Gd-EOB-MRI. • Gd-EOB-MRI and (99m) Tc-mebrofenin HBS show elevated function of non-embolized lobe. • Gd-EOB-MRI and (99m) Tc-mebrofenin HBS can determine lobar liver function.

Selective hypertrophy of the lobus caudatus as a novel approach enabling extended right hepatectomy in the presence of a non-perfused left lateral liver lobe

Introduction

Portal vein embolization (PVE) is a well-established technique to enhance functional hepatic reserves of segments II and III before curative extended right hepatectomy for tumors of the right liver lobe. However, an adequate hepatopetal flow of the left lateral portal vein branches is required for a sufficient PVE-associated hypertrophy.

Case report

Here, we report a 65-year old patient suffering from a locally advanced intrahepatic cholangiocarcinoma in the right liver lobe and segment IV. A curative extended right hepatectomy after preoperative PVE of liver segments IV–VIII was initially impossible because of partial thrombosis of the left lateral portal vein branches resulting in an ischemic-type atrophy of segments II and III. However, due to a massive hypertrophy of the caudate lobe following PVE of liver segments IV–VIII, subsequent extended right hepatectomy with intraoperative thrombectomy of segments II and III was made possible.

Conclusions

To our knowledge this is the first case in which an extended right hepatectomy for a liver malignancy, in the presence of atrophic left lateral section, was made possible by a massive PVE-associated hypertrophy of the caudate lobe.

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.

Evaluation of gadolinium-EOB-DTPA uptake after portal vein embolization: value of an increased flip angle

BACKGROUND

The optimal sequence for Gd-EOB-DTPA uptake measurement in the liver with the purpose of liver function measurement is still not defined.

PURPOSE

To prospectively evaluate the effect of an increased flip angle (FA) of a T1-weighted fat-saturated 3D sequence for the measurement of hepatocyte uptake of Gd-EOB-DTPA magnetic resonance imaging (MRI) after right portal vein embolization (PVE).

MATERIAL AND METHODS

Ten patients who received a PVE prior to an extended hemihepatectomy were examined 14 days after PVE using Gd-EOB-DTPA enhanced MRI of the liver using the standard FA of 10° and the increased FA of 30°.

RESULTS

Relative enhancement of the right liver lobe (RLL) was 0.52 ± 0.12 for 10° and 1.41 ± 0.39 for 30°. Relative enhancement of the left liver lobe (LLL) was 0.58 ± 0.11 for 10° and 2.05 ± 0.61 for 30°. Relative enhancement of the RLL was significantly higher for 30° than for 10° (P = 0.009) and significantly higher in the 30° than in the 10° sequences (P = 0.005) for the LLL.

CONCLUSION

A flip angle of 30° increases the contrast between liver partitions with and without portal venous embolization. Thereby, the sensitivity for differences in uptake intensity is increased. This could be of value for a more exact determination of differences in regional liver function and, consequently, the estimation of the future remnant liver function.

Combined portal vein resection in the treatment of hilar cholangiocarcinoma: a systematic review and meta-analysis

OBJECTIVE

To analyse the efficacy and safety of portal vein resection for hilar cholangiocarcinoma (HCCA).

METHODS

A thorough search of PubMed, the Cochrane Library, Embase, the Chinese BioMedical Literature (CBM), and the Chinese Medical Current Contents (CMCC) databases was performed to identify comparative studies concerning combined portal vein resection (PVR) versus surgery without portal vein resection (Without PVR) and no surgical tumour resection (NR) in the treatment of HCCA.

RESULTS

Thirteen studies with a total of 1921 HCCA cases were included. The results of the meta-analysis revealed that PVR was associated with a poorer overall survival than Without PVR (HR = 1.90; 95%CI 1.59-2.28; P < 0.00001) but was significantly better than NR (HR = 0.33; 95%CI 0.26-0.41; P < 0.00001). The PVR group exhibited significantly higher rates of advanced disease and a higher proportion of lymph node metastasis (OR = 1.50; 95%CI 1.06-2.13; P = 0.02) and perineural invasion (OR = 2.95; 95%CI 1.80-4.84; P < 0.0001), and the PVR group exhibited a lower curative resection rate (OR = 0.65; 95%CI 0.46-0.91; P = 0.01). No significant differences were found between the two groups with respect to postoperative mortality and morbidity.

CONCLUSIONS

Combined PVR is safe and feasible in the treatment of HCCA when the portal vein is grossly involved. For advanced HCCA when the portal vein is grossly involved, surgical resection including PVR can benefit the overall survival in certain patients. However, further randomised controlled trials are necessary to determine the prognostic effects of the addition of PVR to the surgical procedure.

Liver resection for Bismuth type I and Type II hilar cholangiocarcinoma

BACKGROUND

In patients with Bismuth type I and II hilar cholangiocarcinoma (HCCA), bile duct resection alone has been the conventional approach. However, many authors have reported that concomitant liver resection improved surgical outcomes.

METHODS

Between January 2000 and January 2012, 52 patients underwent surgical resection for a Bismuth type I and II HCCA (type I: n = 22; type II: n = 30). Patients were classified into two groups: concomitant liver resection (n = 26) and bile duct resection alone (n = 26).

RESULTS

Bile duct resection alone was performed in 26 patients. Concomitant liver resection was performed in 26 patients (right side hepatectomy [n = 13]; left-side hepatectomy [n = 6]; volume-preserving liver resection [n = 7]). All liver resections included a caudate lobectomy. Patient and tumor characteristics did not differ between the two groups. Although concomitant liver resection required longer operating time (P < 0.001), it had a similar postoperative complication rate (P = 0.764), high curability (P = 0.010), and low local recurrence rate (P = 0.006). Concomitant liver resection showed better overall survival (P = 0.047).

CONCLUSIONS

Concomitant liver resection should be considered in patients with Bismuth type I and II HCCA.

Increase in left liver lobe function after preoperative right portal vein embolisation assessed with gadolinium-EOB-DTPA MRI

OBJECTIVES

To prospectively evaluate the early development of regional liver function after right portal vein embolisation (PVE) with Gd-EOB-DTPA-enhanced MRI in patients scheduled for extended right hemihepatectomy.

METHODS

Ten patients who received a PVE before an extended hemihepatectomy were examined before and 14 days after PVE using Gd-EOB-DTPA-enhanced MRI of the liver. In these sequences representative region of interest measurements were performed in the embolised right (RLL) and the non-embolised left liver lobe (LLL). The volume as well as hepatic uptake index (HUI) was calculated independently for each lobe.

RESULTS

Relative enhancement 14 days after PVE decreased in the RLL and increased significantly in the LLL (P < 0.05). Average hepatic uptake index (HUI) for RLL was significantly lower 14 days after PVE than before PVE (P < 0.05) and significantly higher for LLL (P < 0.05).

CONCLUSIONS

A significant shift of contrast uptake from the right to the left liver lobe can be depicted as early as 14 days after right PVE by using Gd-EOB-DTPA-enhanced MRI, which could reflect the redirected portal venous blood flow and the rapid utilisation of a hepatic functional reserve.

KEY POINTS

• Preoperative portal vein embolisation (PVE) is widely performed before right-sided hepatic resection. • PVE increases intravenous contrast medium uptake in the left lobe of liver. • The hepatic uptake index for the left liver lobe increases rapidly after PVE. • Left liver lobe function increase may be visualised by Gd-EOB-DTPA-enhanced MRI.

Treatment of hilar cholangiocarcinoma of Bismuth-Corlette type III with hepaticojejunostomy

Aim of the study

The present study aims to explore the value of application of hepaticojejunostomy in surgical treatment of Bismuth-Corlette type III hepatic hilar cholangiocarcinoma.

Material and methods

The clinical data of hepaticojejunostomy in 6 patients with Bismuth-Corlette type III hepatic hilar cholangiocarcinoma from January 2008 to October 2011 were retrospectively analyzed. There were 5 males and 1 female, aged 45–69 years, on average 58 years old. There were 3 cases of Bismuth-Corlette type IIIa and 3 cases of Bismuth-Corlette type IIIb.

Results

The 6 patients all successfully underwent hepaticojejunostomy, with operation time of 160–310 min, on average 210 ±28 min. One patient suffered a small amount of bile leakage (3–20 ml) and his drainage tube was taken out after being cured with conservative treatment for 18 days. Three patients showed postoperative mild increases of aspartate aminotransaminase (AST), alanine transaminase (ALT) and AKP, which were improved after drug treatments. There was no biliary stricture in the 6 patients after follow-up for 3–18 months.

Conclusions

Hepaticojejunostomy was simple and flexible, with a good effect on biliary reconstruction of Bismuth-Corlette type III hepatic hilar cholangiocarcinoma. It solved the difficulties in multiple choledochojejunostomy, and with less complications; therefore, it is worth being popularized.

Laparoscopic resection of hilar cholangiocarcinoma

BACKGROUND

Surgical resection is the only curative treatment for hilar cholangiocarcinoma. Laparoscopic hepatectomy has been used to treat several types of liver neoplasms. However, technical issues have limited the adoption of laparoscopy for the treatment of hilar cholangiocarcinoma. To date there is only one report of minimally invasive procedure for hilar cholangiocarcinoma in the literature. The present video-assisted procedure shows a laparoscopic resection of hilar cholangiocarcinoma.

PATIENT AND METHODS

A 43-year-old woman with progressive jaundice due to left-sided hilar cholangiocarcinoma was referred for treatment. The decision was to perform a laparoscopic left hepatectomy with lymphadenectomy and resection of extrahepatic bile ducts. Biliary reconstruction was performed using the hybrid method.

RESULTS

Operative time was 300 minutes with minimum blood loss and no need for blood transfusion. Recovery was uneventful, and the patient was discharged on postoperative Day 7. Pathology revealed a well-differentiated cholangiocarcinoma with negative lymph nodes and clear surgical margins. The patient is well with no signs of the disease 18 months after the procedure.

CONCLUSIONS

Laparoscopic left hepatectomy with lymphadenectomy is safe and feasible in selected patients and when performed by surgeons with expertise in liver surgery and minimally invasive techniques. The use of a hybrid method may be needed for biliary reconstruction, especially in cases where position and size of remnant bile ducts may jeopardize the anastomosis. Further studies are still needed to confirm the benefit of this approach over conventional surgery for hilar cholangiocarcinoma.

Role of caudate lobectomy in type III A and III B hilar cholangiocarcinoma: a 15-year experience in a tertiary institution

BACKGROUND

Concomitant liver resection for type III hilar cholangiocarcinoma could improve the R0 resection rate and long-term outcome. In the present study, we examine the specific role of caudate lobectomy in liver resection for type III(A) and III(B) hilar cholangiocarcinoma and the prognostic factors for survival in this group of patients.

METHODS

We reviewed all patients with type III(A) and III(B) hilar cholangiocarcinoma who underwent liver resection in Samsung Medical Center from January 1995 to July 2010. Patients were divided into those with and without caudate lobectomy (CL). The log rank test and Cox regression analysis were employed to investigate for prognostic factors of survival.

RESULTS

There were 127 patients in this cohort, 57 without CL (44.9%) and 70 with CL (55.1%). The demographics and symptoms of presentation were comparable. The median preoperative bilirubin level was significantly higher in the group undergoing CL (p = 0.017). Patients with CL had a significantly better overall survival (OS) (CL: 64.0 months vs without CL: 34.6 months) (p = 0.010) and disease-free survival (DFS) (CL: 40.5 months vs without CL: 27.0 months) (p = 0.031). Multivariate analysis showed that presence of symptoms (p = 0.025) and positive lymph node (LN) metastasis (p < 0.001) were negative prognostic factors for OS. Furthermore, multivariate analysis for DFS found that caudate lobectomy (p = 0.016) and positive LN metastasis (p = 0.001) were positive and negative prognostic factors, respectively.

CONCLUSIONS

Caudate lobectomy contributed to improvement of DFS and OS in type III hilar cholangiocarcinoma. Other prognostic factors include positive LN metastasis and presence of symptoms.

Efficacy and safety of liver transplantation in patients with cholangiocarcinoma: a systematic review and meta-analysis

The aim of our study was to evaluate the efficacy and safety of liver transplantation in patients with cholangiocarcinoma. According to the requirements of Cochrane systematic review, a thorough literature search was performed in PubMed/Medline, Embase and Cochrane electronic databases between 1995 and 2009 in terms of the key words "liver transplantation" and "cholangiocarcinoma," "cholangiocellular carcinoma" or "bile duct cancer," with restricted articles for the English language. Data were processed for a meta-analysis by Stata 10 software. Altogether 14 clinical trials containing 605 transplanted patients of bile duct cancers were finally enrolled in our study. The overall 1-, 3- and 5-year pooled survival rates were 0.73 [95% confidence interval (CI) = 0.65-0.80], 0.42 (95% CI = 0.33-0.51) and 0.39 (95% CI = 0.28-0.51), respectively. Of note, preoperative adjuvant therapies [orthotopic liver transplantation (OLT)-PAT group] rendered the transplanted individuals with comparably favorable outcomes with 1-, 3- and 5-year pooled survival rates of 0.83 (95% CI = 0.57-0.98), 0.57 (95% CI = 0.18-0.92) and 0.65 (95% CI = 0.40-0.87). In addition, the overall pooled incidence of complications was 0.62 (95% CI = 0.44-0.78), among which that of OLT-PAT group (0.58; 95% CI = 0.20-0.92) was relatively acceptable compared to those of liver transplantation alone (0.61; 95% CI = 0.33-0.85) and liver transplantation with extended bile duct resection (0.78; 95% CI = 0.55-0.94). In comparison to curative resection of cholangiocarcinoma with the 5-year survival rate reported from 20 to 40%, the role of liver transplantation alone is so limited. In the future, attention will be focused on liver transplantation following neoadjuvant radiochemotherapy, which requires a well-designed, prospective randomized controlled study.

Evolution of the surgical management of perihilar cholangiocarcinoma in a Western centre demonstrates improved survival with endoscopic biliary drainage and reduced use of blood transfusion

BACKGROUND

Perihilar cholangiocarcinoma (PHCCA) remains a surgical challenge for which few large Western series have been reported. The aims of this study were to investigate the results of surgical resection for PHCCA and assess how practice has evolved over the past 15 years.

METHODS

A prospectively maintained database was interrogated to identify all resections. Clinicopathological data were analysed for impact on survival. Subsequently, data for resections carried out during the periods 1994-1998, 1999-2003 and 2004-2008 were compared.

RESULTS

Eighty-three patients underwent resection. Trisectionectomy was required in 67% of resections. Overall survival was 70%, 36% and 20% at 1, 3 and 5 years, respectively. Size of tumour, margin (R0) status, lymph node status, distant metastasis, tumour grade, portal vein resection, microscopic direct vascular invasion, T-stage and blood transfusion requirement significantly affected outcome on univariate analysis. Distant metastasis (P = 0.040), percutaneous biliary drainage (P = 0.015) and blood transfusion requirement (P = 0.026) were significant factors on multivariate analysis. Survival outcomes improved and blood transfusion requirement was significantly reduced in the most recent time period.

DISCUSSION

Blood transfusion requirement and preoperative percutaneous biliary drainage were identified as independent indicators of a poor prognosis following resection of PHCCA. Longterm survival can be achieved following the aggressive surgical resection of this tumour, but the emergence of a clear learning curve in our analyses indicates that these patients should be managed in high-volume centres in order to achieve improved outcomes.

Resection and Drainage of Hilar Cholangiocarcinoma: An 11-Year Experience of a Single Center in Mainland China

The purpose of this study is to provide appropriate approaches for resection and drainage of hilar cholangiocarcinomas. Surgical approaches and postoperative survival rates of the patients were analyzed retrospectively. The 1-, 3-, and 5-year cumulative survival rates for patients who underwent resection were 76.6, 36.2, and 10.6 per cent, which was higher than those of 60, 14.3, and 0 per cent, respectively, in palliative operation. Moreover, the 1-, 3-, and 5-year cumulative survival rates for patients who underwent R0 were 88.9, 44.4, and 13.9 per cent, which was improved compared with those of 36.4, 9.1, and 0 per cent, respectively, in nonR0 resection. In addition, the overall survival time of patients who underwent R0 resection combined with hemihepatectomy and caudate lobe resection was longer than of those who underwent R0 without this extra operation, especially within 3 years after operation. After endoscopic metal biliary endoprothesis for patients who were intolerant of resection, liver function was improved at 2 weeks postoperation and the 1-, 3-, and 5-year cumulative survival rates for these patients were 72.7, 18.2, and 0 per cent, respectively. Treatment should be personalized. Resection is the most efficacious therapy, and negative histologic margins should be achieved in radical operation and “skeletonized” surgical operation is the basic requirement of radical treatment of hilar cholangiocarcinoma. Portal vein resection is beneficial to long-term survival and R0 resection combined with caudate lobe resection and hemihepatectomy is more efficacious for patients with Bismuth-Corlette type III hilar cholangiocarcinoma. The preferred approach of drainage in palliative operation is endoscopic metal biliary endoprothesis, which is more appropriate than tumor resection for the patients who suffer from serious comorbidities.

Biliary, pancreatic, and hepatic imaging for the general surgeon

Technologic advancements have allowed imaging modalities to become more useful in the diagnosis of hepatobiliary and pancreatic disorders. Computed tomography scanners now use multidetector row technology with contrast-delayed imaging for quicker and more accurate imaging. Magnetic resonance imaging with cholangiopancreatography can more clearly delineate liver lesions and the biliary and pancreatic ducts, and can diagnose pathologic conditions early in their course. Newer technologies, such as single-operator cholangioscopy and endoscopic ultrasonography, have sometimes shown superiority to traditional modalities. This article addresses the literature regarding available imaging techniques in the diagnosis and treatment of common surgical hepatobiliary and pancreatic diseases.

Aggressive surgical resection for hilar cholangiocarcinoma of the left-side predominance: radicality and safety of left-sided hepatectomy

OBJECTIVES

To evaluate the clinicopathologic outcomes in patients with hilar cholangiocarcinoma (HC) after left-sided hepatectomy (L-H).

SUMMARY BACKGROUND DATA

L-H is indicated as radical surgery for HC, predominantly involving left hepatic duct. However, several reports have demonstrated that L-H often results in tumor-positive margin and unfavorable prognosis compared with right-sided hepatectomy (R-H).

METHODS

A total of 224 patients with HC underwent surgical resection with curative intent at our institution: L-H for Bismuth-Corlette (B-C) type IIIb tumors in 88 patients (39.3%) including 75 left hemihepatectomies and 13 left trisectionectomies, and R-H mainly for B-C type IIIa and IV tumors in 84 patients (37.5%). In this study, clinicopathologic outcomes and perioperative morbidity and mortality rates after L-H were investigated and compared with those after R-H.

RESULTS

Histologically negative margin (R0) resection was achieved in 56 cases (63.6%) with L-H, similar to the results for R-H (58/84, 69.1%). However, the R0 resection rate in L-H cases with portal vein (PV) resection was lower (11/25, 44.0%), and various types of PV reconstruction were required. Proximal ductal stumps and excisional surface at periductal structures were the most common sites of positive margins. However, when curative resection was achieved, 5-year survival was comparable to that in R-H cases. Furthermore, lower mortality was noted in L-H cases, even with left trisectionectomy. Multivariate analysis indicated curability and hepatic artery resection as independent prognostic factors.

CONCLUSIONS

Since L-H is a safe procedure and represents the only curative resectional option for type IIIb tumor, aggressive surgical resection should be performed even in cases with PV involvement, if R0 resection is possible.

[Liver transplantation increases R0 resection and survival of patients with a non-disseminated unresectable Klatskin tumour]

INTRODUCTION

There are no established indications for Liver transplant (LT) in patients with a Klatskin tumour (KT) due to the differences in the published results.

OBJECTIVE

To report on our patients who have non-disseminated unresectable KT and who were given a LT, and to compare results with those of patients who have had tumour resection and those who have not.

PATIENTS AND METHOD

We have treated 75 patients diagnosed with KT. The mean age was 62 + or - 11 years (range: 38-88 years) and 50 were males (66%). Twenty patients were inoperable. Of the 55 patients who underwent surgery: tumour resection (TR) was performed in 29 cases; there was no tumour dissemination in 11 unresectable cases and therefore these patients were added to the LT waiting list and the remaining 15 unresectable cases had tumour dissemination and remained on palliative treatment.

RESULTS

In the LT group there was no postoperative mortality (during the first month) and the survival rate was 95%, 59% and 36% with a disease-free survival of 75%, 40% and 20%; whereas the patients given RT had a survival rate of 80%, 52% and 38% at 1, 3 and 5 years, with a disease-free survival of 65%, 35% and 19%, without any differences compared to the LT group. Patients with unresectable tumour left on palliative therapy had a lower survival than the unresectable who underwent LT (p<0.001).

CONCLUSIONS

In patients with non-disseminated unresectable KT, LT has a similar survival to that obtained in cases with resectable R0 liver resection. LT improves the survival rate achieved using palliative treatment in patients with non-disseminated unresectable KT.

Extent of liver resection for hilar cholangiocarcinoma

BACKGROUND

The extent of liver resection for hilar cholangiocarcinoma (HC) remains controversial despite extensive studies. The aim of this study was to determine the safety and efficacy of minor and major hepatectomy, selected by predetermined criteria in patients with HC.

METHODS

From 2000 to 2007, 187 patients with HC were studied prospectively; 138 patients underwent resection with curative intent. Minor hepatectomy was performed in 93 patients with Bismuth-Corlette type I, II or III HC without hepatic arterial or portal venous invasion, and major hepatectomy in 45 patients with type III HC with hepatic arterial or portal venous invasion, or type IV HC.

RESULTS

Overall mortality and morbidity rates were 0 and 29.7 per cent respectively, and the bile leak rate was 1.4 per cent. Actuarial 1-, 3- and 5-year survival rates were 87, 54 and 34 per cent respectively in the minor liver resection group, and 80, 42 and 27 per cent for major resection (P = 0.300).

CONCLUSION

Minor liver resection for HC, selected by predetermined criteria, had good results. Major liver resection, which had a higher operative morbidity rate than minor resection, should be reserved for Bismuth-Corlette type III HC with vascular invasion, or type IV HC.

Transplantation for cholangiocarcinoma: when and for whom?

Liver transplantation for cholangiocarcinoma has historically been maligned. Because of a high recurrence rate and poor patient survival, the disease has been viewed as an absolute contraindication to transplantation. Based on good results using neoadjuvant and palliative radiation, a protocol for liver transplantation in selected patients with unresectable hilar cholangiocarcinoma was developed in 1993. Neoadjuvant radiation is followed by operative staging to rule out patients with lymph node metastases before liver transplantation. This approach has achieved results superior to standard surgical therapy, with 72% 5-year survival for patients with unresectable disease.

Management of bile duct tumors

Cholangiocarcinomas are a rare but highly fatal disease. The only curative treatment is radical surgical resection of the tumor and the regional lymph nodes. More than half of patients have irresectable disease, which implicates a median survival of < 1 year. The mainstay of palliative treatment is endoscopic or percutaneous drainage of the biliary system. In patients with good performance status, palliative chemotherapy seems to provide some survival benefit together with an improved quality of life. No standard chemotherapy has been defined but gemcitabine monotherapy or the combination of gemcitabine with platin derivates or capecitabine seems to be more effective than other protocols. Additionally, photodynamic therapy has shown promising results and radiation might be helpful for localized disease. In a very selected population liver transplantation can also be an option.