Drain data to predict clinically relevant pancreatic fistula

Background

Post-operative pancreatic fistula (POPF) is a common and potentially devastating complication of pancreas resection. Management of this complication is important to the pancreas surgeon.

Objective

The aim of the present study was to evaluate whether drain data accurately predicts clinically significant POPF.

Methods

A prospectively maintained database with daily drain amylase concentrations and output volumes from 177 consecutive pancreatic resections was analysed. Drain data, demographic and operative data were correlated with POPF (ISGPF Grade: A – clinically silent, B – clinically evident, C – severe) to determine predictive factors.

Results

Twenty-six (46.4%) out of 56 patients who underwent distal pancreatectomy and 52 (43.0%) out of 121 patients who underwent a Whipple procedure developed a POPF (Grade A-C). POPFs were classified as A (24, 42.9%) and C (2, 3.6%) after distal pancreatectomy whereas they were graded as A (35, 28.9%), B (15, 12.4%) and C (2, 1.7%) after Whipple procedures. Drain data analysis was limited to Whipple procedures because only two patients developed a clinically significant leak after distal pancreatectomy.The daily total drain output did not differ between patients with a clinical leak (Grades B/C) and patients without a clinical leak (no leak and Grade A) on post-operative day (POD) 1 to 7. Although the median amylase concentration was significantly higher in patients with a clinical leak on POD 1–6, there was no day that amylase concentration predicted a clinical leak better than simply classifying all patients as ‘no leak’ (maximum accuracy =86.1% on POD 1, expected accuracy by chance =85.6%, kappa =10.2%).

Conclusion

Drain amylase data in the early post-operative period are not a sensitive or specific predictor of which patients will develop clinically significant POPF after pancreas resection.     

Outcome of the pancreatic remnant following segmental pancreatectomy for non-invasive intraductal papillary mucinous neoplasm

ObjectivesIntraductual papillary mucinous neoplasms (IPMNs) are often multifocal and involve the entire pancreas. Because of the morbidity associated with total pancreatectomy, surgeons will perform segmental pancreatectomy, resecting only the most ‘threatening’ IPMN lesion(s). We sought to determine whether the presence of residual IPMN following segmental pancreatectomy for non-invasive IPMN increases the risk for subsequent development of invasive pancreatic cancer and decreases survival.MethodsData on patients undergoing segmental resection of non-invasive IPMN during the period 1991–2010 at a high-volume academic institution were prospectively accrued.ResultsOf 243 patients who underwent segmental resection for IPMN, 191 (79%) demonstrated non-invasive pathology. Of these, 153 (80%) showed the absence and 38 (20%) the presence of residual IPMN at the initial operation. Of the 38 patients with residual IPMN, eight had positive IPMN margins, 23 had radiographic evidence of IPMN, and seven had both. During a mean follow-up of 73 months, 31 (20%) of 153 patients without residual IPMN developed a new radiographic lesion consistent with IPMN and, of these, three (10%) were found to represent invasive cancer. One (3%) of 38 patients with residual IPMN developed invasive cancer. In summary, in 191 initially non-invasive cases of IPMN, four invasive cancers (2%) developed during follow-up. The mean progression-free interval in these four patients was 54 months (range: 20–99 months).ConclusionsCompared with patients undergoing complete operative IPMN clearance, patients with residual IPMN after segmental pancreatectomy do not demonstrate increased risk for the development of invasive disease or reduced survival. In patients without residual IPMN who later develop new IPMN, the risk for invasive IPMN is increased.     

Routine nasogastric suction may be unnecessary after a pancreatic resection

BackgroundMost surgeons routinely place a nasogastric tube at the time of a pancreatic resection. The goal of the present study was to evaluate the outcome when a pancreatic resection is performed without routine post-operative nasogastric suction.MethodsOne hundred consecutive patients underwent a pancreatic resection (64 a pancreaticoduodenectomy, 98% pylorus sparing and 36 a distal pancreatectomy). In the first cohort (50 patients), a nasogastric tube was routinely placed at the time of surgery and in the second cohort (50 patients) the nasogastric was removed in the operating room. Outcomes for these two cohorts were recorded in a prospective database and compared using the χ² or Fisher's exact test and Wilcoxon's rank-sum test.ResultsDemographical, surgical and pathological details were similar between the two cohorts. A post-operative complication occurred in 22 (44%) in each group (P= 1.000). There were no statistically significant differences in the frequency or severity of complications, or length of stay between groups. The spectrum of complications experienced by the two cohorts was similar including complications that could potentially be related to the use of nasogastric suction such as delayed gastric emptying, anastomotic leak, wound dehiscence and pneumonia. There was no difference between the two groups in the number of patients who required post-operative nasogastric tube placement (or replacement) [2 (4%) vs. 4 (8%), P= 0.678].ConclusionIt may be safe to place a nasogastric tube post-operatively in a minority of patients after a pancreatic resection and spare the majority the discomfort associated with routine post-operative nasogastric suction.     

Endoscopic ultrasound-guided choledoco-duodenostomy as an alternative to percutaneous trans-hepatic cholangiography

Background

Endoscopic ultrasonography (EUS)-guided choledochoduodenostomy (CDS) is an alternative to percutaneous transhepatic cholangiography (PTC) drainage in patients with an obstructed biliary system where conventional endoscopic retrograde biliary drainage (ERBD) has been unsuccessful.

Methods

Five EUS-CDS procedures were reviewed to assess whether successful decompression was achieved and maintained.

Results

There was technical success in each instance with no immediate complications. There was a significant fall in the median bilirubin of 164 mmol/l. The median follow-up was 44 days. In one patient the stent migrated with no adverse outcome.

Conclusion

EUS-CDS is a viable alternative to PTC with fewer complications and comparable success rates. EUS-CDS may offer a future route for novel therapeutic advances.     

Pancreatic head resectable adenocarcinoma: preoperative chemoradiation improves local control but does not affect survival

Background

This study assesses the impact of preoperative chemoradiation on recurrence, surgical morbidity, histopathological data and survival in resectable adenocarcinoma of the pancreatic head.

Methods

We carried out a retrospective study with an intention-to-treat analysis. From 1997 to 2006, 173 patients with resectable pancreas head carcinoma were treated in two reference centres in France using different treatment strategies.

Results

Sixty-seven of 85 (79%) patients in the surgery-first (SF) group and 38 of 88 (43%) patients in the chemoradiation (CR) group underwent surgical resection (P < 0.001). Overall morbidity was 40% (15/38) in the CR group and 43% (29/67) in the SF group (P = 0.837). In the CR group, median tumour size was smaller (1.5 cm vs. 3.0 cm; P < 0.001) and fewer patients were node-positive (29% vs. 64%; P = 0.001) than in the SF group. There was less perineural (43% vs. 93%; P < 0.001), lymphatic and vascular (21% vs. 92%; P < 0.001) invasion in the CR group than in the SF group. In both groups, 89% of patients had recurrence (31/35 in the CR group and 57/64 in the SF group; P = 1.000), predominantly involving metastasis and carcinomatosis in the CR group (30/31 vs. 35/57; P < 0.001) and locoregional recurrence in the SF group (24/57 vs. 3/31; P = 0.002). Median survival for all patients and for resected patients in the CR and SF groups was, respectively, 15 months vs. 17 months, and 21 months vs. 18 months (P = non-significant).

Conclusions

Preoperative chemoradiation allows for good local control of the disease but does not increase survival, mainly for reasons of metastatic spread. Other options should be developed to improve both local and distant control of the disease.     

Determination of factors predictive of outcome for patients undergoing a pancreaticoduodenectomy of pancreatic head ductal adenocarcinomas

Introduction

A pancreaticoduodenectomy is the reference treatment for a resectable pancreatic head ductal adenocarcinoma. The probability of 5-year survival in patients undergoing such treatment is 5–25% and is associated with relatively high peri-operative morbidity and mortality. The objective of the present study was to evaluate risk factors predictive of outcome for patients undergoing a pancreaticoduodenectomy for a pancreatic adenocarcinoma.

Methods

This retrospective analysis incorporated data from the Vancouver General Hospital and the British Columbia Cancer Agency (BCCA) from 1999–2007.

Results

The 5-year survival of 100 patients was 12% with a median survival of 16.5 months. Ninety-day mortality was 7%. Predictors of 90-day mortality included age ≥ 80 years (P < 0.001) and an American Society of Anesthesiologists (ASA) score = 3 (P = 0.012) by univariate analysis and age ≥80 years (P < 0.001) by multivariate analysis. The identifiable predictive factor for poor 5-year survival was an ASA score = 3 (P = 0.043) whereas a Dindo–Clavien surgical complication grade ≥ 3 was associated with a worse outcome (P = 0.013). Referral to the BCCA was associated with a favourable 5-year survival (P = 0.001).

Conclusions

The present study identifies risk factors for patient selection to enhance survival benefit in this patient population.     

Splanchnic vein thrombosis in severe acute pancreatitis: a 2-year, single-institution experience

ObjectivesThis study aimed to determine current practice in the management and outcome of splanchnic vein thrombosis complicating acute pancreatitis (AP).MethodsAn audit of prospectively collected data for all patients presenting with AP was conducted. Patients with splanchnic vein thrombosis were grouped according to vessel involvement and whether or not systemic anticoagulation was administered.ResultsOf 127 consecutive patients admitted with AP, 20 had splanchnic venous thrombosis; in all cases the thrombosis was associated with a severe attack of AP. Involvement of the splenic vein (SV), portal vein (PV) and superior mesenteric vein (SMV) was observed in 14, 10 and three patients, respectively. Involvement of more than one vessel was observed in six patients (SV and PV in four patients; SMV and SV in one patient; all three veins in one patient). Thromboses were colocalized with collections in 19 patients. Only four patients received systemic anticoagulation. Resolution of thrombosis was observed in six patients over a median of 77 days. No significant differences were observed in recanalization rates following anticoagulation (P= 0.076). No complications associated with systemic anticoagulation occurred. One patient developed liver failure associated with progressive PV thrombosis and one patient died.ConclusionsSplanchnic vein thrombosis is a relatively common observation in severe AP and is associated with pancreatic necrosis and peripancreatic collections. Recanalization is observed in almost a third of patients, irrespective of whether or not they receive systemic anticoagulation.     

Duct-to-duct biliary reconstruction in patients with primary sclerosing cholangitis undergoing liver transplantation

BackgroundReconstruction of biliary drainage after liver transplantation (LTx) in patients with primary sclerosing cholangitis (PSC) has been a matter of controversy. Over recent years, the traditional method of Roux-en-Y hepaticojejunostomy (RY) has been challenged by duct-to-duct (DD) biliary reconstruction.MethodsThis study represents a retrospective review of biliary complications, patient and graft survival after LTx in PSC patients based on type of biliary reconstruction. Outcomes of DD reconstruction in this group of patients and non-PSC patients are compared.ResultsA total of 53 primary LTx procedures were performed for PSC between August 2005 and July 2010. Seven patients were excluded because unexpected cholangiocarcinoma was found in the explants (n= 3) or because they received partial livers (n= 4). Biliary reconstruction was performed as DD in 18 patients and RY in 28 patients. There were no bile leaks. Anastomotic stricture occurred in two (11%) patients in the DD group and one (4%) in the RY group. Two (7%) patients in the RY group developed non-PSC intrahepatic strictures and one had recurrence of PSC. Rates of 1- and 3-year patient and graft survival in the RY and DD groups were 96.7% and 96.7%, and 100% and 94.5%, respectively. In a group of 34 randomly selected patients transplanted for a non-PSC diagnosis with DD reconstruction during the same period, the anastomotic stricture rate was 9% and 1- and 3-year patient and graft survival rates were 97.0% and 88.5%; differences were not significant.ConclusionsDuct-to-duct biliary reconstruction at the time of LTx in selected PSC patients is both effective and safe, and shows outcomes comparable with those of RY reconstruction in these patients and those of DD reconstruction in non-PSC patients.     

Predictors of peri-opertative morbidity and liver dysfunction after hepatic resection in patients with chronic liver disease

BackgroundHepatic resection in patients with chronic liver disease (CLD) is associated with a risk of post-operative liver failure and higher morbidity than patients without liver disease. There is no universal risk stratification scheme for CLD patients undergoing resection.ObjectivesThe aim of the present study was to evaluate the association between routine pre-operative laboratory investigations, model for end-stage liver disease (MELD), indocyanine green retention at 15 min (ICG15) and post-operative outcomes in CLD patients undergoing liver resection.MethodsA retrospective review of patients undergoing resection for hepatocellular carcinoma (HCC) at the University Health Network was preformed. ICG15 results, pre- and post-operative laboratory results were obtained from clinical records. Adjusted odds ratios (AOR) were calculated for associations between pre-operative factors and post-operative outcomes using multivariate logistic regression adjusting for patient age and number of segments resected.ResultsBetween 2001 and 2005, 129 CLD patients underwent surgical resection for HCC. Procedures included 51 (40%) resections of ≤2 segments, 52 (40%) hemihepatectomies and 25 (19%) extended hepatic resections. Thirty- and 90-day post-operative mortality was 1.6% and 4.1%, respectively. Prolonged (>10 days) hospital length of stay (LOS) was independently associated with an ICG15 >15% {AOR [95% confidence interval (CI)]= 8.5 (1.4–51)} and an international normalized ratio (INR) > 1.2 [AOR (95% CI) = 5.0 (1.4–18.6)]. An ICG15 > 15% and MELD score were independent predictors of prolonged LOS. An ICG15 > 15% was also independently associated with MELD > 20 on post-operative day 3 [AOR (95% CI) = 24.3 (1.8–319)].ConclusionsElevated ICG retention was independently associated with post-operative liver dysfunction and morbidity. The utility of ICG in combination with other biochemical measures to predict outcomes after hepatic resection in CLD patients requires further prospective study.A possible role for ICG clearance in predicting outcome following hepatic resection for hepatocellular carcinoma     

Laparoscopic three-port distal pancreatectomy

Aims

Laparoscopic distal pancreatectomy is becoming a more commonly used procedure, which may involve the use of four to seven ports, depending on the technique. Initial data on feasibility, safety and outcome with the three-port laparoscopic distal pancreatectomy are presented.

Methods

The patient is placed in a partial thoracoabdominal position exposing the left flank in a reverse Trendelenberg position. A 10-mm Hassan trocar is inserted through a subcostal anterior axillary incision. A 5-mm midclavicular and 10-mm posterior axillary line trocar are placed. The specimen is retrieved from the anterior axillary line port.

Results

Ten women and seven men, aged 26–88 years (mean 61 years), were evaluated. Their body mass indexes ranged from 18–37 (mean 27). Pancreatic lesion size ranged from 1.0–5.5 cm (mean 3.0 cm). Operative time was 116–296 min (mean 170 min). Blood loss was 10–300 ml (mean 142 ml). No operation required conversion or additional trocar placement. Post-operative stay was 2–7 days (mean 4 days). No patient developed a pancreatic fistula.

Conclusion

Operative time, blood loss and post-operative stay of this three-port technique compare favourably with published data.     

Inferior vena cava resection with hepatectomy: challenging but justified

ObjectiveThe aim of this study was to evaluate the clinical outcome of hepatectomy combined with inferior vena cava (IVC) resection and reconstruction for treatment of invasive liver tumours.MethodsFrom February 1995 to September 2010, 2146 patients underwent liver resections in our hospital's hepatopancreatobiliary unit. Of these, 35 (1.6%) patients underwent hepatectomy with IVC resection. These patients were included in this study. Data were analysed from a prospectively collected database.ResultsResections were carried out for colorectal liver metastasis (CRLM) (n= 21), hepatocellular carcinoma (n= 6), cholangiocarcinoma (n= 3) and other conditions (n= 5). Resections were carried out with total vascular occlusion in 34 patients and without in one patient. In situ hypothermic perfusion was performed in 13 patients; the ante situm technique was used in three patients, and ex vivo resection was used in six patients. There were four early deaths from multiple organ failure. Postoperative complications occurred in 14 patients, three of whom required re-operation. Median overall survival was 29 months and cumulative 5-year survival was 37.7%. Rates of 1-, 2- and 5-year survival were 75.9%, 58.7% and 19.6%, respectively, in CRLM patients.ConclusionsAggressive surgical management of liver tumours with IVC involvement offers the only hope for cure in selected patients. Resection by specialist teams affords acceptable perioperative morbidity and mortality rates.     

Profile of and risk factors for early unplanned readmissions in patients with acute necrotizing pancreatitis

IntroductionAcute necrotizing pancreatitis (ANP) complicates up to 15% of acute pancreatitis cases. ANP has historically been associated with a significant risk for readmission, but there are currently no studies exploring factors that associate with risk for unplanned, early (<30-day) readmissions in this patient population.MethodsWe performed a retrospective review of all consecutive patients presenting to hospitals in the Indiana University (IU) Health system with pancreatic necrosis between December 2016 and June 2020. Patients younger than 18 years of age, without confirmed pancreatic necrosis and those that suffered in-hospital mortality were excluded. Logistic regression was performed to identify potential predictors of early readmission in this group of patients.ResultsOne hundred and sixty-two patients met study criteria. 27.7% of the cohort was readmitted within 30-days of index discharge. The median time to readmission was 10 days (IQR 5–17 days). The most frequent reason for readmission was abdominal pain (75.6%), followed by nausea and vomiting in (35.6%). Discharge to home was associated with 93% lower odds of readmission. We found no additional clinical factors that predicted early readmission.ConclusionPatients with ANP have a significant risk for early (<30 days) readmission. Direct discharge to home, rather than short or long-term rehabilitation facilities, is associated with lower odds of early readmission. Analysis was otherwise negative for independent, clinical predictors of early unplanned readmissions in ANP.     

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

BackgroundPerihilar 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.MethodsA 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.ResultsEighty-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.DiscussionBlood 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.     

Lymphadenectomy in the staging and treatment of intrahepatic cholangiocarcinoma: a population-based study using the National Cancer Institute SEER database

ObjectivesAlthough lymphatic spread is common in intrahepatic cholangiocarcinoma (ICC), lymphadenectomy is not widely performed as part of operative resection in this disease. The objectives of this study were to assess national trends for lymphadenectomy and its impact on survival in patients with ICC.MethodsThe National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) registry was queried to identify patients with ICC (n= 4893) reported during 1988–2007. Kaplan–Maier and Cox proportional hazards regression were used to analyse survival.ResultsFive-year overall survival (OS) was 5.2%. Lymph node (LN) status was available for 48.9% (n= 2391) of patients. Histologic LN evaluation was performed in 13.5% (n= 658) of patients for a median of two (interquartile range: 1–3) LNs. During the study period, the frequency of histologic LN assessment (P= 0.78) did not change in liver resection patients. In the 733 resected patients, positive vs. negative LN status was associated with worse 5-year OS of 8.4% vs. 25.9%, respectively (hazard ratio = 1.8; P < 0.001).ConclusionsNodal status is an important prognostic factor for survival in patients diagnosed with ICC. In the USA, few patients undergo hepatic resection with lymphadenectomy; therefore, the clinical benefit of formal lymphadenectomy in ICC remains unknown.     

Major venous resection during total laparoscopic pancreaticoduodenectomy

BackgroundThe feasibility of total laparoscopic pancreaticoduodenectomy (TLPD) has been established. Laparoscopic major venous resection during TLPD has not been reported. The aim of the present study was to describe the technique and outcomes of patients undergoing TLPD with major venous resection.MethodsRetrospective review of all consecutive patients undergoing TLPD and major venous resection from July 2007 to December 2010 was performed. Patient demographics and peri-operative outcomes were retrieved. Data are presented as mean ± standard deviation (SD) or median with range.ResultsOut of 129 patients undergoing TLPD, major venous resection was performed in 11 patients with a mean age of 71 years. Median operative time and blood loss was 413 (301–666) min and 500 (75–2800) ml, respectively. Venous resection included tangential (n= 10) and segmental resection (n= 1). Venous reconstruction included patch (n= 4), suture (n= 4), stapled (n= 2) and a left renal vein interposition graft (n= 1). Median mesoportal clamp time was 35 (10–82) min. There was no 30-day or in-hospital mortality. Post-operative imaging was available in 10 patients with 100% patency at the venous reconstruction site.ConclusionsLaparoscopic major venous resection during TLPD is feasible in selected patients. Extensive experience with complex laparoscopic pancreatic resection and reconstruction is advocated before attempting this procedure.     

All cholecystectomy specimens must be sent for histopathology to detect inapparent gallbladder cancer

Objectives

Traditionally, a gallbladder removed for presumed benign disease has been sent for histopathological examination (HPE), but this practice has been the subject of controversy. This study was undertaken to compare patients in whom gallbladder cancer (GBC) was diagnosed after cholecystectomy on HPE with GBC patients in whom the gallbladder was not sent for HPE and who therefore presented late with symptoms.

Methods

A retrospective analysis of prospectively collected data for 170 GBC patients diagnosed after cholecystectomy was conducted. All patients presented to one centre during 2000–2011. These patients were divided into two groups based on the availability of histopathology reports: Group A included patients who presented early with HPE reports (n = 93), and Group B comprised patients who presented late with symptoms and without HPE reports (n = 77).

Results

The median time to presentation in Group A was significantly lower than in Group B (29 days vs. 152 days; P < 0.001). Signs or symptoms suggestive of recurrence (pain, jaundice or gastric outlet obstruction) were present in four (4.3%) patients in Group A and all (100%) patients in Group B (P < 0.001). Patients deemed operable on preoperative evaluation included all (100%) patients in Group A and 38 (49.4%) patients in Group B (P < 0.0001). The overall resectability rate (69.9% vs. 7.8%) and median survival (54 months vs. 10 months) were significantly higher in Group A compared with Group B (P < 0.0001).

Conclusions

Patients in whom a cholecystectomy specimen was sent for HPE presented early, had a better R0 resection rate and longer overall survival. Hence, routine HPE of all cholecystectomy specimens should be performed.     

Ketamine does not inhibit interleukin-6 synthesis in hepatic resections requiring a temporary porto-arterial occlusion (Pringle manoeuvre): a controlled, prospective, randomized, double-blinded study

IntroductionPrevious studies have shown that interleukin-6 (IL-6) levels correlated with mortality in critically ill patients.GoalTo determine the effect of ketamine on IL-6 levels in liver resections patients with a temporary porto-arterial occlusion (Pringle manoeuvre).Materials and methodsControlled, prospective, randomized, double-blinded study. One group (n = 21) received ketamine whereas the other group (n = 17) received placebo. IL-6 levels were obtained at baseline, 4, 12, 24 h, 3 and 5 days.ResultsThere were no significant differences in IL-6 levels between the groups (basal P = 089, 4 h P = 0.83, 12 h P = 0.39, 24 h, P = 0.55, 3 days P = 0.80 and 5 days P = 0.45). Both groups had elevated IL-6 levels that became almost undetectable by day 5. There was no major morbidity and no mortality in either group.ConclusionsKetamine does not seem to have an effect on plasma levels of IL-6. This could be interpreted as a potential finding associated with outcome as we did not encounter any deaths or major complications. Further studies will likely be needed to determine the range of IL-6 levels associated with survival and mortality, and whether it could be a predictor of survival.     

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

ObjectiveCriteria for selecting patients to receive adjuvant chemotherapy in cases of resected intrahepatic or hilar cholangiocarcinoma (CC) are lacking. Some clinicians advocate the provision of adjuvant therapy in patients with lymph node (LN)-positive disease; however, nodal assessment is often inadequate. The aim of this study was to identify a surrogate criterion based on primary tumour characteristics.MethodsAll patients who underwent resection for hilar or intrahepatic CC at a single institution between January 2000 and September 2009 were identified from a prospectively maintained database. Pathological factors were recorded. The primary outcome assessed was overall survival (OS).ResultsIn total, 69 patients underwent resection for hilar (n= 34) or intrahepatic (n= 35) CC. Their median age was 66 years and 27 patients (39%) were male. Median follow-up was 22 months and median OS was 17 months. Median tumour size was 5 cm. Overall, 23% of patients had a positive resection margin, 44% had perineural invasion, 32% had lymphovascular invasion (LVI) and 25% had positive LNs. The median number of LNs removed was two and the median number of positive LNs was zero. The presence of LVI was associated with reduced OS (11.9 months vs. 23.1 months; P= 0.023). After accounting for all other adverse tumour factors, the presence of LVI persisted as the only negative prognostic factor for OS on multivariate Cox regression.ConclusionsIn patients who had undergone resection of hilar or intrahepatic CC, the presence of LVI was strongly associated with reduced OS. Thus the finding of LVI may potentially be used as a criterion in the selection of patients for adjuvant chemotherapy.     

Surgical treatment of intrahepatic cholangiocarcinoma: outcomes and predictive factors

Background

Intrahepatic cholangiocarcinoma (ICC) remains a rare tumour, although its incidence is increasing. Surgical resection is the mainstay of treatment. Published data regarding prognostic factors and optimal patient selection for resection are scant. We sought to determine the clinicopathologic characteristics of resectable ICC and outcomes following surgical treatment.

Methods

We reviewed prospectively collected clinical data including patient, pathologic and operative details. Survival and recurrence outcomes were analysed using Cox hazard models and the Kaplan–Meier method.

Results

We identified 31 surgically treated patients. Their 3-year overall survival rate (OS) was 40.1%; median follow-up was 16.2 months (range: 0.2–86.9 months). R0 resection was associated with significantly improved OS compared with R1/R2 resection (3-year OS was 68.6% in R0 vs. 24.0% in R1/R2; P = 0.042). The postoperative complication rate was 58.1%. Two patients died of postoperative liver failure within 30 days. Preoperative hypoalbuminaemia was significantly associated with worse survival.

Conclusions

Surgical therapy for ICC is associated with longterm survival in the subset of nutritionally replete patients in whom an R0 resection can be achieved. Surgical mortality is significant in patients undergoing extended resection. The margin involvement rate is high and surgeons should consider the infiltrative nature of the disease in operative planning.