Portal vein resection for hilar cholangiocarcinoma

Hilar cholangiocarcinoma remains a difficult challenge for the surgeon. Achieving negative surgical margins when resecting this relatively uncommon tumor is technically demanding as a result of the close proximity of the bile duct bifurcation to the vascular inflow of the liver. A recent advance in surgical treatment is the addition of portal vein resection to the procedure. Resection of the portal vein increases the number of patients offered a potentially curative approach but is technically more difficult and may increase the risk of the procedure. This study reviews the results of portal vein resection for hilar cholangiocarcinoma. Between 1998 and 2005, 60 patients underwent potentially curative resections of hilar cholangiocarcinoma. Mean patient age was 64 +/- 12 years (range, 24-85 years). Liver resections performed along with biliary resection included 49 trisegmentectomies (37 right, 12 left) and 10 lobectomies (8 left, 2 right). One patient had only the bile duct resected. Four patients also had simultaneous pancreaticoduodenectomy performed. Twenty-six patients required portal vein resection and reconstruction to achieve negative margins, 3 of which also required reconstruction of the hepatic artery. Operative mortality was 8 per cent with an overall complication rate of 40 per cent. Patients who underwent portal vein resection had an operative mortality of 4 per cent, which was not different from the 12 per cent mortality in patients who did not undergo portal vein resection (P = 0.39). There was no difference in actuarial patient survival between patients who underwent portal vein resection and those who did not (5-year survival 39 per cent vs. 41 per cent, P = not significant). Negative margins were achieved in 80 per cent of cases and were associated with improved survival (P < 0.01). Five-year actuarial survival in patients undergoing resection with negative margins was 45 per cent. There was no difference in margin status or long-term survival between those patients who underwent portal vein resection and those who did not. Only negative margin status was associated with improved survival by multivariate analysis. Portal vein resection for hilar cholangiocarcinoma is safe and allows a chance for long-term survival in otherwise unresectable patients.     

中下段胆管癌切除后切缘阳性的意义及预后因素分析

目的 分析中下段胆管癌切除术后切缘阳性的意义,研究影响中下段胆管癌切除术后的预后因素.方法 回顾性分析1990年1月至2006年12月收治的79例中下段且日管癌切除患者的临床病理资料.其中男性53例、女性26例,年龄30～79岁,平均61岁.中段胆管癌34例,下段胆管癌45例.行胰十二指肠切除术46例,行根治性胆总管癌切除术25例,行根治性胆总管癌切除联合肝部分切除术6例,行根治性胆总管癌切除联合门静脉部分切除术2例.5例于术后1个月内死亡,对其余74例患者的15项临床病理特征进行单因素及多因素分析.结果 74例患者总的5年生存率为30.7%,中位生存期为36个月.术后病理榆查为镜下切缘阳性(R1切除)16例(20.3%),其中肝脏端胍管切缘阳性6例,远端胆管切缘阳性3例,双侧胆管切缘阳性2例,环周切缘阳性5例.接受R0和Rl切除的患者的5年生存率分别为34.4%和15.5%.10例(17.2%)R0切除的胆管癌出现局部复发,10例(62.5%)R1切除出现复发,差异有统计学意义(X2=13.024,P<0.01).单因素分析显示术前血红蛋白水平、分化程度、肿瘤浸润深度、淋巴结转移、TNM分期及手术切缘为影响预后的因素.多因素分析显示淋巴结转移状况和切缘癌残留是影响预后的独立因素.结论 中下段胆管癌根治术中冰冻病理检查切缘达R0切除是提高长期生存的重要策略,辅助治疗的效果尚待进一步研究.     

Results of surgical resection for patients with hilar bile duct cancer: application of extended hepatectomy after biliary drainage and hemihepatic portal vein embolization

OBJECTIVE: To evaluate the feasibility of an aggressive surgical approach incorporating major hepatic resection after biliary drainage and preoperative portal vein embolization for patients with hilar bile duct cancer. SUMMARY BACKGROUND DATA: Although many surgeons have emphasized the importance of major hepatectomy in terms of curative resection for patients with hilar bile duct cancer, this procedure results in a high incidence of postoperative morbidity and mortality in patients with cholestasis-induced impaired liver function. METHODS: A retrospective cohort study was conducted in 140 patients with hilar bile duct cancer treated from 1990 through 2001. Resectional surgery was performed in 79 patients, 69 of whom underwent major hepatic resection. Thirteen patients underwent concomitant pancreaticoduodenectomy. Preoperative biliary drainage was carried out in all 65 patients who had obstructive jaundice. Portal vein embolization was conducted in 41 of 51 patients undergoing extended right hepatectomy. Short- and long-term outcomes were evaluated. RESULTS: No patient experienced postoperative liver failure (maximum total bilirubin level, 5.4 mg/dL). The in-hospital mortality rate was 1.3% (1 in 79, resulting from cerebral infarction). A histologically negative resection margin was obtained more frequently when the scheduled extended hepatic resection was conducted (75% vs 44%, P = 0.0178). The estimated 5-year survival rate was 40% when histologically negative resection margins were obtained, but only 6% if the margins were positive. Multivariate analysis identified the resection margin and nodal status as independent factors predictive of survival. CONCLUSIONS: Extensive resection, mainly extended right hemihepatectomy, after biliary drainage and preoperative portal vein embolization, when necessary, for patients with hilar bile duct cancer can be performed safely and is more likely to result in histologically negative margins than other resection methods.     

Cholangiocarcinoma: advocate an aggressive operative approach with adjuvant chemotherapy

Cholangiocarcinoma presents many challenges. Prognosis is thought to be determined by conventional predictors of survival; margin status, pathologic criteria, stage, and comorbid disease. Ninety-four patients, 57 males and 37 females, underwent resections for cholangiocarcinoma between 1989 and 2000. Thirty-two patients (34%) had distal tumors, 10 had midduct lesions, and 52 had proximal/intrahepatic lesions. Thirty-four patients underwent pancreaticoduodenectomies, 23 bile duct resections alone, and 37 bile duct and concomitant hepatic resections. Tumor location did not influence mean survival (distal, 28 months +/- 23; midduct, 28 months +/- 21; and proximal, 31 months +/- 36). Operation undertaken did not alter survival (bile duct resection, 30 months +/- 37; pancreaticoduodenectomy, 27 months +/- 23; and concomitant bile duct/hepatic resection, 32 months +/- 32). TNM stage failed to predict survival: 5 stage I (29 months +/- 22), 12 stage II (41 months +/- 33), 12 stage III (33 months +/- 19), and 64 stage IV (27 months +/- 32). Tumor size did not influence survival: T1-2 (32 months +/- 33) versus T3-4 lesions (29 months +/- 25). Mean survival with negative margin (n = 67) was 34 months +/- 33, whereas microscopically positive (n = 13, 23.9 months +/- 25) or grossly positive (n = 14, 20.4 months +/- 20) margins were predictive of significantly shorter survival (P < 0.03). Adjuvant treatment (n = 41) was associated with significantly longer survival (40.5 months +/- 36) than those who received no further therapy (n = 53; 24 months +/- 24) (P = 0.05). TNM stage, tumor size, operation undertaken, and location were not associated with duration of survival after resection. Margin status was associated with duration of survival, though extended survival is possible even with positive margins. Advanced stage should not preclude aggressive resection. Without specific contraindications, an aggressive operative approach is advocated followed by adjuvant therapy.     

Combined vascular resection in operative resection for hilar cholangiocarcinoma: does it work or not?

BACKGROUND: It is still not clear how combined vascular resection affects the outcome of patients with hilar cholangiocarcinoma. Our aim was to evaluate implications of combined vascular resection in patients with hilar cholangiocarcinoma by analyzing the outcomes of all patients who underwent operative resection. METHODS: A total of 161 of 228 consecutive patients with hilar cholangiocarcinoma underwent bile duct resection with various types of hepatectomy (88%) and pancreaticoduodenectomy (4%). Combined vascular resection was carried out in 43 patients. Thirty-four patients had portal vein resection alone, 7 patients had both portal vein and hepatic artery resection, and 2 patients had right hepatic artery resection only. The outcomes were compared between the 3 groups: the portal vein resection alone (34), hepatic artery resection (9), and non-vascular resection (118). RESULTS: Histologically-positive tumor invasion to the portal vein beyond the adventitia was present in 80% of 44 patients undergoing combined portal vein resection. Operative mortality occurred in 11 (7%) patients. The survival rates of the non-vascular resection group were better than that of the portal vein resection alone and the hepatic artery resection groups: 1, 3, and 5 years after curative resection, 72%, 52%, and 41% versus 47%, 31%, and 25% (P < .05), and 17%, 0%, and 0% (P < .0001), respectively. Multivariate analysis showed 4 independent prognostic factors of adverse effect on survival after operation; operative curability, lymph node metastases, portal vein resection, and hepatic artery resection. CONCLUSIONS: Although both portal vein and hepatic artery resection are independent poor prognostic factors after curative operative resection of locally advanced hilar cholangiocarcinoma, portal vein resection is acceptable from an operative risk perspective and might improve the prognosis in the selected patients, however, combined hepatic artery resection can not be justified.     

腹腔镜下中下段胆管癌根治术中联合肝动脉切除重建的疗效与安全性：附3例报告（附视频）

背景与目的：中下段胆管癌临床上主要以下段胆管癌多见,下段胆管癌一般采用胰十二指肠切除术,中段胆管癌可以采用胰十二指肠切除术或胆管癌根治、胆肠吻合术。中下段胆管癌因胆管紧邻肝动脉和门静脉,因此更容易发生门静脉侵犯,因肝动脉有动脉外鞘,因此肝动脉受侵犯相对较少,但一旦侵犯,因为涉及肝动脉切除吻合重建,具有较高技术难度,常需联合肝动脉切除重建才能实现R0切除。目前肝动脉切除重建在临床逐渐成熟,但腹腔镜下完成肝动脉切除重建经验缺乏,需要进一步积累。因此,本研究对3例完成腹腔镜下联合肝动脉切除重建的胆管癌患者的临床资料进行回顾性分析并评估短期结果,以期为临床实践提供初步经验。方法：回顾性分析2021年11月—2022年11月中国人民解放军陆军军医大学第二附属医院肝胆外科的3例行联合肝动脉切除重建的中下段胆管癌根治术患者的临床资料。结果：3例患者中女性1例,男性2例,年龄分别为61、65、69岁;病例1为胆管中段癌,因肿瘤侵犯右肝动脉和门静脉,且胆管下端切缘阴性,行联合右肝动脉切除重建、门静脉切除重建、胆管癌切除、胆肠吻合术、肝门部胆管整形术、淋巴结清扫术;病例2为胆管下段癌,因肿瘤侵犯替代右肝动...     

Cholangiocarcinoma: thirty-one-year experience with 564 patients at a single institution

OBJECTIVE: To assess long-term survival and prognostic factors in a large series of patients with bile duct cancer. SUMMARY BACKGROUND DATA: The incidence of bile duct cancer is low but increasing. Determinants of survival vary in the literature, due to a lack of sufficient numbers of patients in most series. METHODS: We studied 564 consecutive patients with bile duct cancer operated upon between 1973 and 2004. Patients were divided into intrahepatic, perihilar, and distal groups. Principle outcome measures were complications, 30-day mortality, and survival. RESULTS: Of the 564 patients, 44 (8%) had intrahepatic, 281 (50%) had perihilar, and 239 (42%) had distal tumors. Approximately half (294, 52%) were treated before 1995, while 270 (48%) were treated thereafter. The perioperative mortality rate was 4%. In log-rank analyses, survival was higher in the later time period (P = 0.002), in patients with intrahepatic disease (P = 0.001), with negative resection margins (P < 0.001), with well/moderately differentiated tumors (P < 0.001), and those with negative lymph nodal status (P < 0.001). In multivariate analysis, negative margins (P < 0.001), tumor differentiation (P < 0.001), and negative nodal status (P < 0.001), but not tumor diameter, were significant independent prognostic factors. In R0-resected patients, lymph node status (P < 0.001), but not tumor diameter, histology, or differentiation, further predicted survival. The median survivals for R0-resected intrahepatic, perihilar, and distal tumors were 80, 30, and 25 months, respectively, and the 5-year survivals were 63%, 30%, and 27%, respectively. CONCLUSION: R0 resection remains the best chance for long-term survival, and lymph node status is the most important prognostic factor following R0 resection.     

Is pancreaticoduodenectomy with portal vein resection indicated in patients with ductal pancreatic carcinoma?]

Infiltration of the portal vein is almost always regarded as a contraindication for pancreaticoduodenectomy in patients with pancreatic cancer. However, progress in many fields has changed the postoperative situation and mortality of pancreaticoduodenectomy is now below 5%. The aim of the present study was therefore to actually evaluate morbidity, mortality and prognosis of extended pancreaticoduodenectomy combined with protal vein resection for adenocarcinoma of the pancreatic head. Between September 1985 and May 1997 315 patients with a ductal pancreatic carcinoma were treated in our hospital. Resection was possible in 96 cases (partial pancreaticoduodenectomy n = 82, total pancreaticoduodenectomy n = 5, left pancreatic resection n = 9). In 10 cases the portal vein or the mesenteric vein had to be resected. Postoperative complications were seen in 25% of all cases after pancreaticoduodenectomy without portal vein resection and in 20% following extended pancreaticoduodenectomy. The mortality was 5% resp. 0% in both groups. The median survival time of patients after pancreaticoduodenectomy without portal vein resection was 11.9 months (R0 resection: 13.6 months; R1/2 resection 8 months) in contrast to 13.4 months in cases with portal vein resection. In conclusion, these results demonstrate that in special cases of adenocarcinoma of the pancreatic head extended pancreaticoduodenectomy with portal vein resection may be indicated. These patients show a better prognosis than those after palliative procedures. Morbidity and mortality of pancreaticoduodenectomy with portal vein resection is not higher as compared to pancreaticoduodenectomy alone.     

Benefit of venous resection for ductal adenocarcinoma of the pancreatic head.

OBJECTIVE: To find out whether there is any benefit from venous resection during pancreaticoduodenectomy for ductal pancreatic adenocarcinoma. DESIGN: Retrospective study. SETTING: University Hospital Mannheim/Heidelberg, Germany. INTERVENTIONS: 271 patients had resections for ductal adenocarcinoma of the pancreatic head between 1980 and 2001. The outcome of patients who did (n = 68) and who did not (n = 203) have simultaneous resection of major veins (portal vein and/or superior mesenteric vein) were compared. MAIN OUTCOME MEASUREMENT: 5 year survival. RESULTS: The groups differed significantly regarding stage, perineural infiltration, lymphangiosis carcinomatosa, operating time, blood loss, and blood transfusion. However, there was no difference in perioperative morbidity (27% and 22%), mortality (4% and 3%), and long-term survival (at 5 years 23% and 24%). Subgroup analysis of patients with margins free of tumour (R0 resections) showed that those patients who had venous resections in whom histological examination did not show infiltration of tumour had the most favourable outcome. CONCLUSION: There is no reason to exclude patients with suspected venous infiltration from radical pancreaticoduodenectomy including venous resection.     

Combined Major Hepatectomy and Pancreaticoduodenectomy for Locally Advanced Biliary Carcinoma: Long-Term Results

BACKGROUND: This study aimed to define the role of combined major hepatectomy and pancreaticoduodenectomy in the surgical management of biliary carcinoma and to identify potential candidates for this aggressive procedure. METHODS: A retrospective analysis was conducted on 28 patients who underwent a combined major hepatectomy and pancreaticoduodenectomy for extrahepatic cholangiocarcinoma (n = 17) or gallbladder carcinoma (n = 11). Major hepatectomy was defined as hemihepatectomy or more extensive hepatectomy. Altogether, 11 patients underwent a Whipple procedure, and 17 had a pylorus-preserving pancreaticoduodenectomy. The median follow-up time was 169 months. RESULTS: Morbidity and in-hospital mortality were 82% and 21%, respectively. Overall cumulative survival rates after resection were 32% at 2 years and 11% at 5 years (median survival time 9 months). The median survival time was 6 months with a 2-year survival rate of 0% in 11 patients with residual tumor, whereas the median survival time was 26 months with a 5-year survival rate of 18% in 17 patients with no residual tumor (P = 0.0012). Residual tumor status was the only independent prognostic factor of significance (relative risk 4.65; P = 0.003). There were three 5-year survivors (two with diffuse cholangiocarcinoma and one with gallbladder carcinoma with no bile duct involvement) among the patients with no residual tumor. CONCLUSIONS: Combined major hepatectomy and pancreaticoduodenectomy provides survival benefit for some patients with locally advanced biliary carcinoma only if potentially curative (R0) resection is feasible. Patients with diffuse cholangiocarcinoma and gallbladder carcinoma with no bile duct involvement are potential candidates for this aggressive procedure.     

Prognostic factors of surgical resection in middle and distal bile duct cancer: an analysis of 55 patients concerning the significance of ductal and radial margins

BACKGROUND: The surgical outcome of middle and/or distal bile duct cancer remains unsatisfactory. Although the resectional margin is known to be a predictive factor, the prognostic significance of a positive ductal margin and other radial margin has never been evaluated independently. METHODS: The clinicopathologic data of 55 patients who had undergone surgical resection for middle and/or distal bile duct cancer between 1987 and 2003 were reviewed retrospectively. The surgical procedures consisted of pancreatoduodenectomy in 42 patients (76%), extrahepatic bile duct resection in 8 patients (15%), major hemihepatectomy (Hx) in 3 patients (5%), and pancreatoduodenectomy plus Hx in 2 patients (4%). In all the patients, intraoperative diagnosis of the ductal margins was performed using frozen sections. Twenty-one clinicopathologic factors, including the status of the ductal margins and of other radial margins, were evaluated using univariate and multivariate analyses. RESULTS: The overall 5-year survival rate and the median survival time were 24% and 38 months, respectively. There were 4 (7%) postoperative deaths. Fifteen of the remaining 51 patients (29%) were determined to have positive hepatic-side ductal margins during operation, and 14 of them underwent additional resection of the bile duct (1.6[range, 1-3] times, on average). As a result, hepatic-side ductal margin (hm) and duodenal-side ductal margin were found to be positive in 6 and 0 patients on the final pathologic analysis, respectively. Two of the 6 patients (33%) with positive hm have developed ductal recurrence so far, but the status of hm was not found to be a significant predictor. The depth of neoplastic invasion into the bile duct wall, pancreatic invasion, radial margin, and blood transfusion were significant prognostic factors by the univariate analysis. Multivariate analysis revealed that the depth of neoplastic invasion and blood transfusion were the independent prognostic factors. CONCLUSIONS: In the treatment of middle and distal bile duct cancer, it is of importance to secure a negative radial margin, although it may be less beneficial to obtain a negative hm. Surgeons should make efforts to obtain negative radial margins and to avoid blood transfusion.     

Clinical Implications of Combined Portal Vein Resection as a Palliative Procedure in Patients Undergoing Pancreaticoduodenectomy for Pancreatic Head Carcinoma

Background The clinical implications of combined portal vein resections are controversial.Methods One-hundred and forty-nine consecutive patients underwent macroscopically curative pancreatectomies for pancreatic head carcinoma between January 1, 1996 and December 31, 2004. Portal vein resection was performed in 86 patients (58%). Data on surgical mortality, morbidity, perioperative outcome, pathological factors, initial recurrence site, and survival were retrospectively compared between the patients with and without portal vein resection.Results The incidence of postoperative pancreatic fistula was lower among patients who underwent portal vein resection. The median survival period was 14 months for the portal vein resection group and 35 months for the non-portal vein resection group, respectively. Combined portal vein resection was a significant predictor of poor survival using a multivariate analysis. Portal vein resection was strongly associated with larger tumor size, the degree of retropancreatic tissue invasion, the presence of extrapancreatic nerve plexus invasion, lymph node metastases, and positive cancer infiltration at the surgical margins.Conclusions Portal vein resection at the time of pancreaticoduodenectomy can be safely performed. However, most of patients requiring portal vein resection do not achieve a potentially curative resection or a favorable survival term. As a result, the aggressive application and the strict selection of portal vein resection might reduce the incidence of positive surgical margins, enabling long-term survival in patients who do not require portal vein resection.     

Prognostic factors after pancreatoduodenectomy for distal bile duct cancer

Prognostic factors influencing long-term survival after radical resection for distal bile duct cancer have not been well established because of the rarity of this malignancy. The goal of this study was to identify main prognostic factors in patients undergoing pancreatoduodenectomy for distal bile duct carcinoma. A retrospective study consisting of 122 patients with distal bile duct cancer who underwent pancreatoduodenectomy in three major university hospitals was performed to identify the main prognostic factors. Major surgical complications occurred in 40 patients (32.8%), of whom eight died (6.6%) in the hospital. Overall actuarial survival (excluding hospital deaths) at 1-, 3-, and 5-year follow-up was 82.9, 49.4, and 32.7 per cent, respectively, with a median survival of 36 months. Univariate analysis showed that papillary tumor (P = 0.045), negative surgical margin (R0 resection, P = 0.005), earlier pT (P = 0.005), pTNM stage (P < 0.001), and absence of lymph node involvement (P < 0.0001) were significant predictors of survival. On multivariate analysis, only lymph node metastasis was shown to be an independent prognostic factor of survival (P = 0.036). Lymph node involvement was the most important survival predictor after a Whipple resection in patients with distal cholangiocarcinoma.     

Favourable prognostic factors in a large UK experience of adenocarcinoma of the head of the pancreas and periampullary region

AIMS: To present the surgical experience in a regional unit, analysing the post-operative outcome, and determining risk factors for survival after pancreaticoduodenectomy for periampullary and pancreatic head carcinoma. METHODS: Data were collected on 251 patients with pancreatic head adenocarcinoma (133), ampullary carcinomas (88) and distal common bile duct (30), between 1987 and 2002. Survival was calculated using the Kaplan-Meier method. Clinical, surgical and histopathological records were examined by univariate and multivariate analysis to identify the independent prognostic predictors of survival. RESULTS: Median actuarial survival for carcinoma of the pancreatic head, ampulla and distal bile duct were 13.4, 35.5 and 16 months, respectively; p < 0.0001. On univariate analysis for the whole series, the age < or =60, tumour of the head of the pancreas, lymph node positive, resection margin R1, poorly differentiated tumours, and portal vein invasion significantly decreased survival. On multivariate analysis, poor tumour differentiation, surgical margin, lymph node metastases, and age independently influence survival. Mortality and morbidity were 4.8 and 29.9%, respectively. CONCLUSIONS: Pancreaticoduodenectomy for pancreatic and periampullary tumours is the only therapy that may cure patients and can be performed safely in centres with significant experience.     

Extrahepatische distale Gallenwegskarzinome

Malignancies of the biliary tree are classified into three groups according to location: intrahepatic, central (perihilar), and distal. Of all cholangiocarcinomas, 25% are located distally and can be subdivided into middle and lower bile duct carcinomas. Surgical approaches for achieving tumor-free resection margins (R0) are directly associated with the origin of the tumor. Intrahepatic and central cancers usually must be treated by liver surgery, whereas the majority of distal cholangiocarcinomas require pancreaticoduodenectomy. In case of a small, middle bile duct carcinoma, exclusive extrahepatic bile duct resection without pancreatic resection can be adequate. Five-year survival after radical resection is about 25%. Cancer of the distal bile duct has to be distinguished from ductal adenocarcinoma of the pancreas and carcinoma of the ampulla of Vater. Curative surgery is possible if the tumor is diagnosed early and radical resection is feasible. In this context, the role of an extended lymph node dissection remains unclear. To improve survival, future studies are needed to evaluate the role of novel adjuvant strategies (i.e., gemcitabine, capecitabine).     

Laparoscopic pancreaticoduodenectomy: technique and outcomes

BACKGROUND: We describe our experience with laparoscopic pancreaticoduodenectomy, including 5-year actuarial survival rates. STUDY DESIGN: This is a retrospective study of selected patients who underwent laparoscopic pancreaticoduodenectomy at a single center between 1998 and 2006. We have described the salient features of our technique and followup protocol. Patient characteristics, histologic variety of the tumor, resection margins, morbidity, mortality, and actuarial survival rates were studied. RESULTS: The procedure could be completed laparoscopically with tumor-free margins in all patients, including patients with ampullary carcinoma (n = 24), pancreatic cystadenocarcinoma (n = 4), pancreatic head adenocarcinoma (n = 9), low common bile duct cancer (n = 3), and two patients with chronic pancreatitis with a suspicious mass lesion in the head of pancreas. Mean age of patients was 61 years (range 28 to 70 years). There was a single perioperative mortality. Overall followup rate was 95.1%, with two patients lost to followup at 22 and 36 months. Among the survivors, two patients have metastatic disease and local recurrence developed in one patient. Five-year actuarial survival rates for all patients with malignancy, ampullary adenocarcinoma, pancreatic cystadenocarcinoma, pancreatic head adenocarcinoma, and common bile duct adenocarcinoma are 32%, 30.7%, 33.3%, 19.1%, and 50%, respectively. Presence of microscopic lymph node involvement is associated with poor survival, although operations in the setting of chronic pancreatitis resulted in increased morbidity. CONCLUSIONS: Laparoscopic pancreaticoduodenectomy can be performed with safety and good results in properly selected patients. Localized malignant lesions, irrespective of histopathology, are particularly amenable to this approach.     

Surgical management of proximal bile duct cancer: extended right lobe resection increases resectability and radicality

Background: Surgical resection provides the only chance of cure for patients suffering from hilar cholangiocarcinoma. Although appropriate procedures are not agreed upon, an increase in radicality has been observed during the past 20 years.Methods: The literature as well as our own experience after 133 resections of hilar cholangiocarcinomas were reviewed.Results: Tumor-free margins represent the most important prognostic parameter. Hilar resections as least radical resective procedure will generate rates of formally curative resections of less than 50%. Even after these formally curative resections, long-term survival cannot be achieved. Only additional liver resections will increase the number of long-term survivors to significant figures. In our series, the best 5-year survival rate of 72% was achieved after right trisegmentectomy with concomitant resection of the portal vein bifurcation.Conclusion: Right trisegmentectomy and combined portal vein resection represent the best way to comply with basic rules of surgical oncology for hilar cholangiocarcinoma. This procedure will provide the most pronounced benefit among various types of liver resection, whereas local resections of the extrahepatic bile duct must be considered as an oncologically inefficient procedure.     

One hundred and eleven liver resections for hilar bile duct cancer

A positive correlation between absence of residual tumor at resection margins and long-term survival in the treatment of hilar bile duct carcinoma has encouraged some surgeons to use a more radical approach, including liver/portal vein resection and combined pancreatoduodenectomy. However, if liver resection is associated with significant morbidity and mortality, it may not produce any overall benefit. This review was undertaken in an attempt to determine whether liver resection is a safe procedure and whether if has any beneficial effect over that of local bile duct excision alone, in terms of achieving curative resection and long-term survival. The records of 151 patients with hilar bile duct carcinoma surgically treated between June 1989 and December 1997 at the Asan Medical Center, Seoul, were retrospectively analyzed. Surgical resection was possible in 128 patients. The remaining 23 patients had surgical palliative drainage. Local bile duct excision alone was performed in 17 patients. Liver resection for tumor extending to secondary bile ducts or hepatic parenchyma was performed in 111 patients; portal vein resection was necessary in 29 of these 111 patients (26.1%) and pancreatoduodenectomy was combined in 18 patients (16.2%). Seven patients died during hospitalization after liver resection, an operative mortality of 6.3%. Margins of bile duct resection were free of tumor on histologic examination in 4 of the 17 local bile duct excisions, but in 86 of the 111 liver resections. The cumulative survival rate after local bile duct excision was 85.7% at 1 year, 42.9% at 2 years, 21.4% at 3 years, and 0% at 4 years. However, the survival rate after liver resection (excluding operative mortality) was 97.1% at 1 year, 72.8% at 2 years, 55.3% at 3 years, and 24.0% at 5 years. Survival and the percentage of patients with tumor-free resection margins after liver resection were superior to those after local bile duct excision. Resection of hilar bile duct carcinoma offers long-term survival only when surgery is aggressive and includes liver resection. Received for publication on July 2, 1998; accepted on July 5, 1998     

远端胆管癌切除患者术后生存的影响因素分析

目的 研究影响远端胆管癌手术预后的因素,为远端胆管癌手术方式的选择和治疗提供依据.方法 对北京世纪坛医院、北京大学人民医院和北京大学第一医院1995-2009年具有完整随访资料的103例远端胆管癌病例进行回顾性分析,应用Kaplan-Meier单因素分析法和Cox比例风险模型多因素分析法对10个可能对预后产生影响的因素进行分析.结果 1、3、5年总体生存率分别为72%、41%和25%,中位生存期为24.13个月;单因素方差分析结果表明手术方式、淋巴结转移、TNM分期和切缘情况与远端胆管癌术后生存有关;Cox比例风险模型多因素分析结果表明切缘情况、淋巴结转移和TNM分期是影响远端胆管癌切除术后预后的独立因素.结论 切缘情况、淋巴结转移和TNM分期为远端胆管癌切除术后有关生存影响的独立因素,胰十二指肠切除术为远端胆管癌首选的手术方式.     

Outcome of Surgical Treatment of Hilar Cholangiocarcinoma

To evaluate surgical results and the effect of adjuvant chemotherapy in cases of hilar cholangiocarcinoma, we retrospectively analyzed 27 consecutive patients who underwent surgical resection (eight bile duct resections, 18 bile duct resections plus hepatectomy, one hepatopancreaticoduodenectomy). There was no operative mortality, and the morbidity was 37%. Curative resection (R0 resection) was achieved in 20 (74%) patients. Overall survival at 3 and 5 years was 44% and 27%, significantly higher than that of 47 patients who did not undergo resection (3.5% and 0% at 3 and 5 years, p < 0.0001). Survival of patients with positive margins (R1/2 resection) was poor; there were no 5-year survivors. However, survival was better than that of patients who did not undergo resection (median survival: 22 vs 9 months, p = 0.0007). Univariate analysis identified lymph node metastasis as a negative prognostic factor (p = 0.043). Median survival of patients who underwent adjuvant chemotherapy was significantly longer than that of patients who did not (42 vs. 22 months, p = 0.0428). Resection should be considered as the first option for hilar cholangiocarcinoma. There appears to be a survival advantage even in patients with cancer-positive margins. Adjuvant chemotherapy may increase long-term survival.