Prognostic Factors After Surgical Resection for Intrahepatic, Hilar, and Distal Cholangiocarcinoma

Background

The prognosis of patients with cholangiocarcinoma is unsatisfactory. Therefore, evaluation of prognostic factors and establishment of new therapeutic strategies are needed to improve their long-term survival. The aim of this study was to identify useful prognostic factors for patients with intrahepatic, hilar, and distal cholangiocarcinoma.

Materials and Methods

Records of 127 patients with cholangiocarcinoma (21 with intrahepatic cholangiocarcinoma, 50 with hilar cholangiocarcinoma, and 56 with distal cholangiocarcinoma) who underwent surgical resection were reviewed retrospectively. Relationships between survival and clinicopathological factors including patient demographics and tumor characteristics were evaluated using univariate and multivariate analysis.

Results

For all 127 patients, overall 1-, 3-, 5-year survival rates were 80, 51, and 40%, respectively. Univariate analysis revealed that adjuvant chemotherapy (P = .049), tumor differentiation (P = .014), lymph node metastasis (P < .001), surgical margin status (P < .001), UICC pT factor (P < .001), and UICC stage (P < .001) were associated significantly with survival. UICC pT factor (P = .007), adjuvant chemotherapy (P = .009), surgical margin status (P = .012), and lymph node metastasis (P = .014) remained independently associated with long-term survival by multivariate analysis. The 5-year survival rates of patients with or without positive surgical margins were 13 and 49%, respectively. The 5-year survival rates of patients treated with or without adjuvant chemotherapy were 47 and 36%, respectively.

Conclusions

R0 resection and adjuvant chemotherapy may be mandatory to achieve long-term survival for patients with cholangiocarcinoma.     

Surgical Resection and Prognostic Analysis of 142 Cases of Hilar Cholangiocarcinoma

Surgical resection for hilar cholangiocarcinoma is the only curative option, but low resectability rate and poor survival outcomes remain a challenge. This study was to assess the surgical resection for hilar cholangiocarcinoma and analyze the prognostic factors influencing postoperative survival. One hundred forty-two patients with hilar cholangiocarcinoma who underwent surgical resection between January 2006 and December 2014 were analyzed retrospectively based on clinicopathological and demographic data. Univariate and multivariate analysis against outcome were employed to identify potential factors affecting prognosis. Ninety-five patients were performed with R0 resection with median survival time of 22 months; whereas, 47 patients underwent non-R0 resection (R1 = 20, R2 = 27) with that of 10 months. Of these 95 patients, 19 underwent concomitant with vascular resection and reconstruction and 2 patients underwent pancreaticoduodenectomy. 64.8% patients (n = 92) underwent combined with hepatectomy. The one-year, three-year, and five-year survival rates after R0 resection were 76.3, 27.8, 11.3%, respectively, which was significantly better than that after non-curative resection (P = 0.000). Multivariate analysis revealed that non-curative resection (RR: 2.414, 95% CI 1.586–3.676, P = 0.000), pathological differentiation (P = 0.015) and preoperative serum total bilirubin above 10 mg/dL (RR: 1.844, 95% CI 1.235–2.752, P = 0.003) were independent prognostic factors. Aggressive curative resection remains to be the optimal option for hilar cholangiocarcinoma. Non-curative resection, pathological differentiation, and preoperative serum total bilirubin above 10 mg/ dL were associated with dismal prognosis.     

Improved Outcome of Resection of Hilar Cholangiocarcinoma (Klatskin Tumor)

Background Treatment of hilar cholangiocarcinoma (Klatskin tumors) has changed in many aspects. A more extensive surgical approach, as proposed by Japanese surgeons, has been applied in our center over the last 5 years; it combines hilar resection with partial hepatectomy for most tumors. The aim of this study was to assess the outcome of a 15-year evolution in the surgical treatment of Klatskin tumors. Methods A total of 99 consecutive patients underwent resection for hilar cholangiocarcinoma in three 5-year time periods: periods 1 (1988–1993; n = 45), 2 (1993–1998; n = 25), and 3 (1998–2003; n = 29). Outcome was evaluated by assessment of completeness of resection, postoperative morbidity and mortality, and survival. Results The proportion of margin negative resections increased significantly from 13% in period 1 to 59% in period 3 (P < .05). Two-year survival increased significantly from 33% ± 7% and 39% ± 10% in periods 1 and 2 to 60% ± 11% in period 3 (P < .05). Postoperative morbidity and mortality were considerable but did not increase with this changed surgical strategy (68% and 10%, respectively, in period 3). Lymph node metastasis was, next to period of resection, also associated with survival in univariate analysis. Conclusions Mainly in the last 5-year period (1998–2003), when the Japanese surgical approach was followed, more hilar resections were combined with partial liver resections that included segments 1 and 4, thus leading to more R0 resections. This, together with a decrease in lymph node metastases, resulted in improved survival without significantly affecting postoperative morbidity or mortality.     

Intrahepatic Cholangiocarcinoma: Prognostic Factors After Surgical Resection

Background  Intrahepatic cholangiocarcinoma (ICC) is the second most common primary liver tumor. The resectability rate is low because at the time of diagnosis this disease is frequently beyond the limits of surgical therapy. Curative resection (R0) is the most effective treatment and the only therapy associated with prolonged disease-free survival. Based on the gross appearance of the tumor the Liver Cancer Study Group of Japan (LCSGJ) defined three types: mass-forming type (MF), periductal infiltrating type (PI), intraductal growth (IG) type. The prognostic significance of gross type has been demonstrated in Eastern countries, but this issue has not been clarified in Western countries. The aim of this study was to identify the prognostic factors for survival in a group of patients submitted to surgical resection for ICC. Methods  Between 1990 and 2007 a total of 81 consecutive patients with ICC were submitted to surgery. Patients with peritoneal carcinomatosis, extensive vascular involvement, or multiple intrahepatic metastases were excluded from surgical resection. Tumors were classified according to TMN stage (6th edition, 2002) and LCSGJ gross type classification. Tumor gross appearance on the cut surface was categorized into the following types according to the classification proposed by the Liver Cancer Study Group of Japan: MF, PI, or IG type. Results  During the study period 52 patients were submitted to surgical resection with curative intent, whereas in 29 patients surgery was limited to explorative laparotomy. Curative resection (R0) was achieved in 43 patients (83%); and a major hepatic resection was performed in 63% (33/52) of the patients. Extrahepatic bile duct resection was carried out in 36% (19/52) of cases. According to the LCSGJ classification, the MF type was present in 34 patients (65%), the MF + PI type in 13 (25%), the PI type in 3 (6%), and the IG type in 2 (4%). Overall median survival time was 40 months, with a 1-, 3-, and 5-year actuarial survival rates of 83%, 50%, 20%, respectively. Survival was significantly related to the macroscopic gross type, with a median survival of 50 months for patients with the MF type, 19 months for the MF + PI type, 15 months for the PI type, and 17 months for the IG type. At univariate analysis, the macroscopic gross appearance of the tumor, the presence of lymph node metastasis, involvement of extrahepatic bile ducts, the presence of macroscopic vascular invasion, and positive resection margins were significant related to survival. At multivariate analysis, macroscopic vascular invasion and lymph nodes metastases were significant related to survival with hazard ratios of 4.11 and 2.79, respectively. Further statistical analyses were carried out to identify the relation between macroscopic gross type and prognosis. We identified that the MF + PI type tumors were significantly associated with negative prognostic factors, such as the involvement of extrahepatic bile ducts, the presence of lymph nodes metastases, the presence of macroscopic vascular invasion, the presence of perineural invasion, and higher T stage. Conclusions  Curative resection of ICC is the only therapy that can achieve long-term survival. The best results were observed in patients who underwent R0 resection for MF tumors without lymph node metastases or vascular invasion. Important predictive factors related to poor survival are MF + PI macroscopic tumor type, lymph node metastases, and vascular invasion. In these patients, other therapeutic approaches (i.e., adjuvant or neoadjuvant therapy) should be evaluated to improve results.     

肝门部胆管癌切除术不同手术方式的选择

目的探讨肝门部胆管癌切除术不同手术方式的选择。方法近五年来我院共收治肝门部胆管癌25例，其中手术切除17例，切除率为68％，参照Bismuth－Corlette分型选择不同的手术方式，包括Ⅰ型（肝总管癌）5例，Ⅱ型（汇合部肝管癌）3例，Ⅲa型（肝总管、右肝管癌）4例，Ⅲb型（肝总管、左肝管癌）4例，Ⅳ型（左或右肝管癌侵犯二级以上肝管）1例。结果术后发生胆漏5例，均于手术后5—30d自愈；发生膈下感染2例，经引流治愈；术后出血2例，其中1例因出现肝衰、DIC死亡，1N经用止血药、输血后痊愈。目前存活7例，平均生存25（12～42）个月。全组病例1、2、3年生存率分别为75．0％（12／16）、31．2％（5／16）、25．0％（4／16）。结论肝门部胆管痛手术根治性切除府根据肿瘤的分到洗柽不同的术式．     

Surgical Outcome and Prognostic Factors in Intrahepatic Cholangiocarcinoma

BACKGROUND: The clinicopathologic features and surgical outcome of intrahepatic cholangiocarcinoma are not fully understood. METHODS: Fifty-six consecutive patients with intrahepatic cholangiocarcinoma who underwent surgical resection at the National Cancer Center Hospital East between October 1992 and July 2007 were retrospectively analyzed. Intrahepatic cholangiocarcinomas were subdivided into solitary tumors and tumors with intrahepatic metastasis. RESULTS: Complete tumor removal (R0 resection) was performed in 42 patients (75%). The 5-year survival rate for patients with intrahepatic cholangiocarcinoma (n = 56), patients with a solitary tumor (n = 46), and patients with intrahepatic metastasis (n = 10) were 32, 38, and 0%, respectively. There was a significant difference in survival between patients with a solitary tumor and those with intrahepatic metastasis (p < 0.0001). The 5-year survival rate for patients with stage I (n = 3), II (n = 9), III (n = 15), and IV disease (n = 26) was 100, 67, 37, and 0%, respectively. There was a significant difference in survival between stage I and stage IV (p = 0.011), between stage II and stage IV (p = 0.0002), and between stage III and stage IV (p = 0.0015). The most frequent site of recurrence was the liver. Univariate analysis showed that intrahepatic metastasis, portal vein invasion, hepatic duct invasion, lymph node metastasis, perineural invasion, and positive surgical margin (R1) were significantly associated with poor survival. Multivariate analysis confirmed that intrahepatic metastasis was a significant and independent prognostic indicator after surgical resection for intrahepatic cholangiocarcinoma (p = 0.001). No patient with intrahepatic metastasis survived more than 10 months in this study. CONCLUSIONS: Intrahepatic metastasis was the strongest predictor of poor survival in intrahepatic cholangiocarcinoma.     

Oncological Superiority of Hilar En Bloc Resection for the Treatment of Hilar Cholangiocarcinoma

Purpose

Long-term results after liver resection for hilar cholangiocarcinoma are still not satisfactory. Previously, we described a survival advantage of patients who undergo combined right trisectionectomy and portal vein resection, a procedure termed “hilar en bloc resection.” The present study was conducted to analyze its oncological effectiveness compared to conventional hepatectomy.

Patients

During hilar en bloc resection, the extrahepatic bile ducts were resected en bloc with the portal vein bifurcation, the right hepatic artery, and liver segments 1 and 4 to 8. With this “no-touch” technique, preparation of the hilar vessels in the vicinity of the tumor was avoided. The long-term outcome of 50 consecutive patients who underwent curative (R0) hilar en bloc resection between 1990 and 2004 was compared to that of 50 consecutive patients who received curative conventional major hepatectomy for hilar cholangiocarcinoma (perioperative deaths excluded).

Results

The 1-, 3-, and 5-year survival rates after hilar en bloc resection were 87%, 70%, and 58%, respectively, which was significantly higher than after conventional major hepatectomy. In the latter group, 1-, 3-, and 5-year survival rates were 79%, 40%, and 29%, respectively (P = 0.021). Tumor characteristics were comparable in both groups. A high number of pT3 and pT4 tumors and patients with positive regional lymph nodes were present in both groups. Multivariate analysis identified hilar en bloc resection as an independent prognostic factor for long-term survival (P = 0.036).

Conclusions

In patients with central bile duct carcinomas, hilar en bloc resection is oncologically superior to conventional major hepatectomy, providing a chance of long-term survival even in advanced tumors.

     

肝门胆管癌切除的处理体会

目的：总结肝门胆管癌手术处理的临床经验与体会。方法：采用肝门上入路法切除Bismuth Ⅲ-Ⅳ型肝门胆管癌。结果：在23例肝门胆管癌中：属I型者1例，Ⅱ型6例，Ⅲ型11例，Ⅳ型5例。行根治性切除者18例（78．26％）。结论：肝门上入路是肝门被肿瘤禁锢时的唯一人肝路径，肝正中裂路径由于没有主要的胆管成功脉通过，出血少，暴露清楚。方叶切除可帮助完成肝门部胆管癌（距肿瘤边缘1．0cm)的切除。     

Surgical Resection of Hilar Cholangiocarcinoma: Analysis of Survival and Postoperative Complications

Background Surgery is the only potentially curative treatment for hilar bile duct cancer. This study sought to evaluate the efficacy and feasibility of surgical management of hilar bile duct carcinoma, including radical hepatectomy, at a single institution. Methods We performed a retrospective review of 49 consecutive patients who underwent surgery at our hospital between 1990 and 2003. Results Altogether, 44 of 49 patients underwent radical hepatectomy combined with caudate lobectomy and lymphadenectomy. One and four patients underwent partial hepatectomy or bile duct resection, respectively. No patients underwent preoperative portal vein embolization. The 5-year survival rate was 39.7%, with a median survival time of 3.75 years. The postoperative morbidity and mortality rates were 46.8% and 2.0%, respectively. Cox’s proportional hazard model revealed that lymph node status and the residual tumor factor were independent prognostic factors. Multivariate analysis revealed that preoperative hyperbilirubinemia, postoperative complications, and extended surgical procedures were independently associated with postoperative hyperbilirubinemia. After potentially curative resection, 39.4% of patients suffered from disease recurrence. In 60% of the total cases, the sites of recurrence were distant metastases. Conclusion Surgery, including radical hepatectomy combined with caudate lobectomy and lymph node dissection, is a feasible, effective treatment for hilar bile duct cancer.     

Resectable Hilar Cholangiocarcinoma: Surgical Treatment and Long-Term Outcome

Unresected hilar cholangiocarcinoma has a dismal prognosis, but advances in staging and surgical techniques have given well-selected patients a chance of long-term survival if curative resection is possible. This review summarizes the state of the art in diagnosis, treatment, and outcome for patients with biliary obstruction at the hilus of the liver.     

One-stage Resection for Bismuth Type IV Hilar Cholangiocarcinoma with High Hilar Resection and Parenchyma-preserving Strategies: A Cohort Study

Background

Bismuth type IV hilar cholangiocarcinoma (HC) tumors are usually considered unresectable. The strategies of high hilar resection while preserving liver parenchyma can achieve potentially one-stage curative resection for this condition. The aim of the present study was to investigate the feasibility and safety of available strategies.

Methods

Fifty-one consecutive patients with bismuth type IV HC who underwent one-stage resection were retrospectively reviewed with regard to curative resection rate, remnant liver volume, morbidity, mortality, and survival time.

Results

The total median survival time was 29 months. The R₀ (curative resection) rate was 57.8 %. The ratio of the remnant liver volume (RLV) to the standard liver volume (SLV) ranged from 35.0 to 60.6 %, with a mean of 44.5 %. The in-hospital mortality and morbidity rates were 3.9 and 37.2 %, respectively. In the R₀ patients’ survival, there was not a significant difference between bilioenteric anastomosis and hepatoenteric anastomosis (P = 0.714).

Conclusions

Combined caudate lobe and high hilar resection (CCHR) is technically safe and oncologically justifiable and could be adopted with a high cure rate as a one-stage resection procedure for most patients with Bismuth type IV HC whose total bilirubin level is less than 20 mg/L and whose direct bilirubin is more than 60 % of total bilirubin.     

联合血管切除及重建在进展期肝门部胆管癌切除中的应用

对肝胆外科医生而言,肝门部胆管癌仍然是目前最困难的挑战:肝十二指肠韧带处解剖复杂,胆管分叉与入肝血管过于接近,往往难以获得阴性的外科切缘.我们在临床中对肝门部胆管癌进行切除时发现,有近80%的患者存在血管侵犯,以门静脉侵犯多见,且有些同时伴有肝动脉侵犯.     

Surgical Outcome of Hilar Plate Resection: Extended Hilar Bile Duct Resection Without Hepatectomy

Background

We have done curative or palliative extended extrahepatic bile duct resection at the level of the hilar plate for selected patients with cholangiocarcinoma with hilar spreading, calling this procedure “hilar plate resection” (HPR), but the results of evaluating the clinical benefits of HPR for cholangiocarcinoma with hilar spreading have not been reported.

Patients and Methods

Fifty-two patients with cholangiocarcinoma underwent HPR: the curative procedure was performed in 28 patients (cHPR group) and the palliative in 24 patients (pHPR group). In the same period, 128 patients with cholangiocarcinoma underwent major hepatectomy with intrahepatic cholangiojejunostomy (Hx group). These groups were compared in terms of post-operative complications and survival.

Results

There were no significant differences in the rate of patients with post-operative complications and in post-operative hospital stay. The overall cumulative 5-year survival rates for each procedure (Hx group, cHPR group and pHPR group) were 40, 38 and 11 %, respectively. There was no significant difference between the Hx and cHPR groups in survival rates (p?=?0.87).

Conclusion

In conclusion, HPR appears to be safe and feasible for selected patients with cholangiocarcinoma. However, the indications for HPR should be restricted.     

Surgical Management and Prognostic Factors of Hilar Cholangiocarcinoma: Experience with 115 Cases in China

Background  Hilar cholangiocarcinoma (or Klatskin tumor) is a rare condition, accounting for less than 1% of all cancers. This study was designed to assess the surgical and postsurgical management of affected patients, including the postoperative chemotherapy, and an analysis to determine prognostic factors for postoperative morbidity and mortality. Methods  A retrospective review of 115 consecutive cases treated with resection between January 1990 and January 2004 at a single university medical center in southern China was carried out. Clinicopathological data were analyzed and univariate and multivariate analyses against outcome was employed to determine the prognostic significance of a variety of factors including excision margin characteristics, status of metastases, tumor type, histological differentiation, lymph node characteristics, and postoperative therapy. Results  Median survival time of patients treated with resection and anastomosis with postoperative chemotherapy was 41 months compared with 36 months for patients who did not receive chemotherapy postoperatively. Factors correlating with shorter survival were positive excision margin, metastasis, adenoacanthoma-type tumor, poor or unknown histological differentiation, and positive lymph nodes. In addition, postoperative chemotherapy improved survival. Patients treated with chemotherapy postoperatively had a survival of 43.15 ± 21.02 months, which was significantly longer than the survival of patients who received no postoperatively chemotherapy (36.97 ± 15.99 months; P < 0.05). Conclusion  Resection with anastomosis and postoperative chemotherapy results in longer survival time compared with no chemotherapy postoperatively. Positive excision margins, metastases, adenoacanthoma-type tumor, poor or unknown histological differentiation, and positive lymph nodes correlate with shorter survival.     

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.     

晚期肝门胆管癌内镜支架术后生存时间多因素分析

目的:探讨影响晚期肝门部胆管癌患者内镜支架术后生存时间的主要因素。方法:行内镜治疗的61例晚期肝门部胆管癌患者,选择可能对术后生存时间有影响的10个因素进行单因素分析,通过Cox比例风险模型对其进行多因素分析。结果:单因素分析显示,肿瘤的扩散、胆碱酯酶、白蛋白、碱性磷酸酶、谷丙转氨酶及谷草转氨酶的水平影响患者内镜支架术后的预后(P<0.05),Cox比例风险模型多因素分析显示,肿瘤的扩散、白蛋白及胆碱酯酶的水平是影响预后的独立危险因素。结论:影响晚期肝门部胆管癌患者内镜支架术后的独立危险因素,是肿瘤的扩散、胆碱酯酶及白蛋白水平。     

腹腔镜下肝门部胆管癌根治术中淋巴结廓清方法的探讨

目的探讨腹腔镜下肝门部淋巴结廓清的可行性。方法 2007年6月~2009年6月对35例肝门部胆管癌施行腹腔镜下肝门部胆管癌根治术,探查明确肿瘤可以切除,超声刀将胆总管远端在十二指肠上方离断,远侧断端缝合或圈套线结扎闭合,并将胰腺上方的淋巴结一并切除,将胆总管向前上方分离至肿瘤上方约0.5~1.0 cm,离断,超声刀切开肝十二指肠韧带前包膜,找到肝固有动脉,打开动脉鞘后用冲洗吸引器向近肝侧钝性分离纤维脂肪组织,直至显露左右肝动脉的分叉部,同样处理门静脉,直至显露门静脉左右分叉部,除门静脉和肝动脉外,将肝十二指肠韧带内组织整块切除,完成肝门部肿瘤切除及淋巴结廓清,然后镜下使用腔镜直线切割吻合器(5例)或左上腹3~4 cm切口提出空肠行空肠间吻合后还纳回腹腔,重建气腹行胆管-空肠Roux-en-Y吻合(30例)。结果 35例均在腹腔镜下完成肝门部胆管癌根治术并进行淋巴结廓清。清扫淋巴结8~13枚,平均9.3枚,2例发现淋巴结转移。胆肠吻合在镜下完成,肠间吻合5例在镜下使用腔镜直线切割吻合器完成,30例于腹外吻合后还纳回腹,重新气腹完成胆肠吻合。手术时间3.5~5.8 h,平均4.4 h;术中出血量10~210ml,平均83 ml。术后出现胆汁漏3例,未特殊处理,5~7 d后停止。应激性溃疡1例,抑酸药物治疗后3 d治愈。肝左外叶切除术后第5天出血1例,出血量约300 ml,腹腔镜下探查见肝门处毛细血管出血,圈套线结扎止血,术后10 d出院。35例随访6~30个月,平均16.2月,1例术后12个月因肝转移癌死亡,1例术后15个月因突发心肌梗塞死亡,其余33例存活。结论腹腔镜下进行肝门部胆管癌根治性切除同时进行肝门部淋巴结廓清,是完全可以实现的,但需要严格选择病例以及丰富的腹腔镜手术经验,术后远期效果仍然需要进一步观察。     

腹腔镜辅助下肝门部胆管癌根治术38例

目的探讨腹腔镜辅助下肝门部胆管癌根治切除术的可行性。方法五孔法。切除胆囊、肝左内叶下段的肝组织,中上段胆管,切断距肿瘤1 cm处的肝侧胆管。清除肝固有动脉、门静脉周围的纤维脂肪组织及淋巴结。左、右肝管盆式成形,左上腹辅助4～5 cm小切口腹腔外胆肠Roux-en-Y吻合。结果 38例肝门部胆管癌根治术均在腹腔镜下完成。5例肠间吻合于镜下使用吻合器完成;33例先扩大左上腹小切口于腹外吻合后还纳回腹,重新气腹完成胆肠吻合。手术时间210～348 min,（267±47）min;术中出血10～210 ml,（82.6±63.5）ml。术后出现胆漏3例,未特殊处理,3～5 d后停止;应激性溃疡1例,抑酸药物治疗后3 d治愈;术后出血1例,在腹腔镜下手术止血。术后住院10～15 d,平均12 d。17例术后1周CEA均恢复正常,2.7～3.5μg/L,（2.73±0.49）μg/L;38例CA199术后均下降,但未恢复正常,40～90 U/ml,（69.4±20.1）U/ml。术后35例（92.1%）随访6～30个月,（12.5±5.8）月,1例术后12个月因转移癌死亡,1例术后15个月因突发心肌梗塞死亡,其余33例随访期间未见明确转移病灶。结论腹腔镜辅助下肝门部胆管癌根治切除术是可行的,在达到根治切除目的前提下,减轻手术创伤,利于术后康复,术者应同时具有开腹和腹腔镜手术的经验和技巧。     

Combined Portal Vein Resection for Hilar Cholangiocarcinoma: A Meta-analysis of Comparative Studies

Hilar cholangiocarcinoma (HCCA) frequently invades into the adjacent portal vein, and portal vein resection (PVR) is the only way to manage this condition and achieve negative resection margins. However, the safety and effectiveness of PVR is controversial. Studies analyzing the effect of PVR on the surgical and pathological outcomes in the management of HCCA with gross portal vein involvement were considered eligible for this meta-analysis. The outcome variables analyzed included postoperative morbidity, mortality, survival rate, proportion of R0 resection, lymph node metastasis, microscopic vascular invasion, and perineural invasion. From 11 studies, 371 patients who received PVR and 1,029 who did not were identified and analyzed. Data from patients who received combined PVR correlated with higher postoperative death rates (OR?=?2.31; 95 % CI, 1.21–4.43; P?=?0.01) and more advanced tumor stage. No significant difference was detected in terms of morbidity, proportion of R0 resection, or 5-year survival rate. Subgroup analysis demonstrated that in centers with more experience or studies published after 2007, combined PVR did not cause significantly higher postoperative death. No strong evidence could suggest that combined PVR leads to more morbidity or mortality for patients with HCCA when the portal vein is grossly involved. In addition, combined PVR is oncologically valuable because R0 resection and 5-year survival did not differ significantly between two cohorts, despite the fact that the PVR cohort consisted of patients with more advanced HCCA.     

Surgical Outcomes and Predicting Factors of Curative Resection in Patients with Hilar Cholangiocarcinoma: 10-Year Single-Institution Experience

Background

The surgical resection of hilar cholangiocarcinoma is extremely challenging because the tumor is closely related with the complicated hilar structures. We investigated to identify the outcomes for patients who underwent surgical resection and to identify the parameters that influenced radical resection.

Methods

From January 2000 to December 2009, 105 patients underwent surgical resection for hilar cholangiocarcinoma. The clinicopathological parameters and surgical outcomes were retrospectively analyzed.

Results

There were 15 operative mortalities (14.3%). Seventy-four patients underwent curative resection (70.5%). The median overall survival time for R0, R1, and R2 were 58, 28, and 19?months, respectively. Caudate lobectomy (p?=?0.044; odds ratio [OR], 4.386) and perineural invasion (p?=?0.01; OR, 0.062) were correlated with curative resection. Total bilirubin levels of more than 3?g/dl just before the operation (p?=?0.042; hazard ratio [HR], 2.109) and extent of resection (R1 and 2 vs R0; p?=?0.05; HR, 2.309) were selected as significantly negative factors affecting overall survival on the multivariate analysis.

Conclusions

Caudate lobectomy and neurectomy may be thought of as adjustable territories by the surgeon??s efforts to achieve curative resection. R0 resection achieved through those efforts and liver optimization using preoperative biliary drainage may offer the patients a chance of cure.