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Nakano Y, Abe Y, Udagawa D, Kitago M, Hasegawa Y, Hori S, Tanaka M, Uemura S, Odaira M, Mihara K, Nishiyama R, Chiba N, Hayatsu S, Kawachi S, Kitagawa Y. Safety and efficacy of pancreaticogastrostomy for hepatopancreatoduodenectomy compared to pancreaticojejunostomy for perihilar cholangiocarcinoma. World J Surg Oncol 2025; 23:97. [PMID: 40114143 PMCID: PMC11924735 DOI: 10.1186/s12957-025-03737-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2024] [Accepted: 03/07/2025] [Indexed: 03/22/2025] Open
Abstract
BACKGROUND Hepatopancreatoduodenectomy (HPD) is one of the most challenging surgeries for perihilar cholangiocarcinoma. Postoperative pancreatic fistula (POPF) is a critical and fatal complication. The safety and efficacy of pancreaticogastrostomy (PG) for HPD compared to pancreaticojejunostomy (PJ) remain unclear. In this study, we aimed to investigate and compare the short-term outcomes of PG and PJ for HPD in terms of the POPF rate. METHODS Two groups of patients (PG group vs. PJ group) were retrospectively compared between January 2013 and January 2024. The reconstruction method was changed from PJ to PG in March 2021. RESULTS A total of 50 patients were enrolled in this study. The PG and PJ groups comprised 15 (30.0%) and 35 (70.0%) patients, respectively. In the PJ group, three (8.6%) patients died after surgery because of clinically relevant POPF (CR-POPF), intraabdominal bleeding, and post-hepatectomy liver failure. The operative time was longer in the PG group (909 min vs. 706 min, P = 0.020); however, the CR-POPF rate was lower in the PG group than in the PJ group (0 [0%] vs. 19 [54.3%], P < 0.001). Moreover, the number of patients who developed massive postoperative ascites (≥ 1,500 mL/day) was lower in the PG group than in the PJ group (3 [20.0%] vs. 16 [45.7%] patients, P = 0.028). CONCLUSIONS Changing the method of pancreatic reconstruction for HPD from PJ to PG improved the short-term outcomes of patients at our institution. PG reconstruction is safe and effective for HPD as it reduces the incidence of CR-POPF.
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Affiliation(s)
- Yutaka Nakano
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinju-ku, Tokyo, 160-8582, Japan
| | - Yuta Abe
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinju-ku, Tokyo, 160-8582, Japan.
| | - Daisuke Udagawa
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinju-ku, Tokyo, 160-8582, Japan
| | - Minoru Kitago
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinju-ku, Tokyo, 160-8582, Japan
| | - Yasushi Hasegawa
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinju-ku, Tokyo, 160-8582, Japan
| | - Shutaro Hori
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinju-ku, Tokyo, 160-8582, Japan
| | - Masayuki Tanaka
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinju-ku, Tokyo, 160-8582, Japan
| | - Sho Uemura
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinju-ku, Tokyo, 160-8582, Japan
| | - Masanori Odaira
- Department of Surgery, Tokyo Saiseikai Central Hospital, 1-4-17 Mita, Minato-ku, Tokyo, 108- 0073, Japan
| | - Kisyo Mihara
- Department of Surgery, Kawasaki Municipal Hospital, 12-1 Shinkawadori, Kawasaki-ku, Kawasaki-shi, Kanagawa, 210-0013, Japan
| | - Ryo Nishiyama
- Department of Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi- ku, Yokohama, Kanagawa, 230-0012, Japan
| | - Naokazu Chiba
- Department of Surgery, Tokyo Medical University Hachioji Medical Center, 1163, Tatemachi, Hachioji, Tokyo, 193-0998, Japan
| | - Shigeo Hayatsu
- Department of Surgery, National Hospital Organization Saitama Hospital, 2-1 Suwa, Wako-shi, Saitama, 351-0102, Japan
| | - Shigeyuki Kawachi
- Department of Surgery, National Hospital Organization Saitama Hospital, 2-1 Suwa, Wako-shi, Saitama, 351-0102, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinju-ku, Tokyo, 160-8582, Japan
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Umemura K, Shimizu A, Notake T, Kubota K, Hosoda K, Yasukawa K, Kamachi A, Goto T, Tomida H, Soejima Y. Minimum proportion of future liver remnant in safe major hepatopancreatoduodenectomy. Ann Gastroenterol Surg 2025; 9:188-198. [PMID: 39759991 PMCID: PMC11693579 DOI: 10.1002/ags3.12850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 07/16/2024] [Accepted: 07/29/2024] [Indexed: 01/07/2025] Open
Abstract
Background and Aim Post-hepatectomy liver failure (PHLF) after major hepatopancreatoduodenectomy (HPD) is a challenge to overcome. However, the appropriate target proportion of the future liver remnant (pFLR) to prevent severe PHLF in major HPD remains uncertain. This study aimed to determine the minimum pFLR required for safe major HPD. Methods This retrospective study involved 48 major HPD patients. We assessed pFLR and remnant liver function scores (pFLR × albumin-bilirubin [ALBI] / albumin-indocyanine green evaluation [ALICE]/plasma clearance rate of indocyanine green [KICG]) as predictors for Grade B/C PHLF and established safety criteria. Results Grade B/C PHLF occurred in 40% of the patients (n = 19), leading to severe morbidity and two in-hospital deaths. pFLR was a good predictor of Grade B/C PHLF [area under the curve (AUC) 0.80, p < 0.01] with a 45% optimal cutoff. While all remnant liver function scores predicted PHLF, the remnant ALICE demonstrated the best predictability (AUC 0.85, p < 0.01), with the sensitivity and specificity at 89% and 83%, respectively, using -0.86 as the cutoff. Independent risk factors for Grade B/C PHLF were remnant ALICE ≥-0.86 and blood loss ≥1500 mL. Grade B/C PHLF developed in 14% with pFLR ≥45% but reached 64% with pFLR <45%. However, the rate could be reduced to 33% with remnant ALICE <-0.86. Conclusion To prevent Grade B/C PHLF, a pFLR ≥45% is recommended. Nevertheless, major HPD may be considered in patients with good remnant liver function.
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Affiliation(s)
- Kentaro Umemura
- Division of Gastroenterological, Hepato‐Biliary‐Pancreatic, Transplantation and Pediatric Surgery, Department of SurgeryShinshu University School of MedicineMatsumotoJapan
| | - Akira Shimizu
- Division of Gastroenterological, Hepato‐Biliary‐Pancreatic, Transplantation and Pediatric Surgery, Department of SurgeryShinshu University School of MedicineMatsumotoJapan
| | - Tsuyoshi Notake
- Division of Gastroenterological, Hepato‐Biliary‐Pancreatic, Transplantation and Pediatric Surgery, Department of SurgeryShinshu University School of MedicineMatsumotoJapan
| | - Koji Kubota
- Division of Gastroenterological, Hepato‐Biliary‐Pancreatic, Transplantation and Pediatric Surgery, Department of SurgeryShinshu University School of MedicineMatsumotoJapan
| | - Kiyotaka Hosoda
- Division of Gastroenterological, Hepato‐Biliary‐Pancreatic, Transplantation and Pediatric Surgery, Department of SurgeryShinshu University School of MedicineMatsumotoJapan
| | - Koya Yasukawa
- Division of Gastroenterological, Hepato‐Biliary‐Pancreatic, Transplantation and Pediatric Surgery, Department of SurgeryShinshu University School of MedicineMatsumotoJapan
| | - Atsushi Kamachi
- Division of Gastroenterological, Hepato‐Biliary‐Pancreatic, Transplantation and Pediatric Surgery, Department of SurgeryShinshu University School of MedicineMatsumotoJapan
| | - Takamune Goto
- Division of Gastroenterological, Hepato‐Biliary‐Pancreatic, Transplantation and Pediatric Surgery, Department of SurgeryShinshu University School of MedicineMatsumotoJapan
| | - Hidenori Tomida
- Division of Gastroenterological, Hepato‐Biliary‐Pancreatic, Transplantation and Pediatric Surgery, Department of SurgeryShinshu University School of MedicineMatsumotoJapan
| | - Yuji Soejima
- Division of Gastroenterological, Hepato‐Biliary‐Pancreatic, Transplantation and Pediatric Surgery, Department of SurgeryShinshu University School of MedicineMatsumotoJapan
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Umino R, Nara S, Mizui T, Takamoto T, Ban D, Esaki M, Hiraoka N, Shimada K. Impact of Surgical Margin Status on Survival and Recurrence After Pancreaticoduodenectomy for Distal Cholangiocarcinoma: Is Microscopic Residual Tumor (R1) Associated with Higher Rates of Local Recurrence? Ann Surg Oncol 2024; 31:4910-4921. [PMID: 38679686 DOI: 10.1245/s10434-024-15313-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 04/03/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Patients undergoing macroscopically curative resection for distal cholangiocarcinoma (DCC) have high recurrence rates and poor prognoses. This study aimed to investigate the impact of surgical margin status on survival and recurrence after resection of DCC, specifically focusing on microscopic residual tumor (R1) and its relationship to local recurrence. PATIENTS AND METHODS This was a retrospective analysis of patients who had undergone pancreaticoduodenectomy (PD) for DCC between 2005 and 2021. Surgical margin was classified as R0, R1cis (positive bile duct margin with carcinoma in situ), and R1inv (positive bile duct margin with an invasive subepithelial component and/or positive radial margin). RESULTS In total, 29 of 133 patients (21.8%) had R1cis and 23 (17.3%) R1inv. The 5-year overall survival (OS) for R0 (55.7%) did not differ significantly from that for R1cis/R1inv (47.4%/33.6%, respectively). The 5-year recurrence-free survival (RFS) for R0 was significantly longer than that for R1inv (50.1% vs. 17.4%, p = 0.003), whereas RFS did not differ significantly between those with R0 and R1cis. R1cis/R1inv status was not an independent predictor of OS and RFS in multivariate analysis. Cumulative incidence of isolated distant recurrence was significantly higher for R1cis/R1inv than for R0 (p = 0.0343/p = 0.0226, respectively), whereas surgical margin status was not significantly associated with rates of local or local plus distant recurrence. CONCLUSIONS Surgical margin status does not significantly impact OS and RFS in patients undergoing PD for DCC following precise preoperative imaging evaluation. Additionally, R1 status is significantly linked to higher isolated distant recurrence rather than local recurrence, highlighting the importance of multidisciplinary therapy.
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Affiliation(s)
- Ryosuke Umino
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Satoshi Nara
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan.
| | - Takahiro Mizui
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Takeshi Takamoto
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Daisuke Ban
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Minoru Esaki
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Nobuyoshi Hiraoka
- Department of Molecular Pathology, National Cancer Center Hospital, Tokyo, Japan
| | - Kazuaki Shimada
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
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Zhou Y, Li D, You J, Zeng S, Yu W. Hepatopancreatoduodenectomy for Locally Advanced Gallbladder Cancer: Is It Worthwhile? Indian J Surg 2022. [DOI: 10.1007/s12262-022-03471-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Sugiura T, Uesaka K, Ashida R, Ohgi K, Okamura Y, Yamada M, Otsuka S. Hepatopancreatoduodenectomy With Delayed Division of the Pancreatic Parenchyma: A Novel Technique for Reducing Pancreatic Fistula. ANNALS OF SURGERY OPEN 2021; 2:e112. [PMID: 37637883 PMCID: PMC10455438 DOI: 10.1097/as9.0000000000000112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 11/06/2021] [Indexed: 11/26/2022] Open
Abstract
Objectives To review our novel technique of hepatopancreatoduodenectomy (HPD) with delayed division of the pancreatic parenchyma (DDPP) for reducing postoperative pancreatic fistula (POPF). Background The high operative morbidity and mortality rates after HPD remains a major issue. One of the most troublesome complications is POPF, which might possibly be caused by peripancreatic saponification due to long interval between pancreas resection and reconstruction, as most surgeons prefer a caudocranial approach, performing pancreatoduodenectomy (PD) first and then hepatectomy (conventional HPD [C-HPD]). Methods A review of the patients undergoing C-HPD and HPD with DDPP was performed. Postoperative outcomes were compared. Multivariable analysis was conducted to evaluate the risk factors of POPF after HPD. Results One-hundred two patients comprised of 50 patients undergoing C-HPD and 52 patients undergoing HPD with DDPP. The interval between pancreas resection and reconstruction was significantly shorter in HPD with DDPP group than in C-HPD group (51 vs 263 minutes; P < 0.001). The incidence of POPF was significantly lower in HPD with DDPP group than in C-HPD group (32.7% vs 77.3%; P < 0.001). The postoperative hospital stay was shorter in patients undergoing HPD with DDPP than in those undergoing C-HPD (32 vs 45 days). A multivariate analysis revealed that body mass index >24 kg/m2 and conventional (PD first) procedure were significant risk factors for POPF after HPD. Conclusions A novel technique of HPD with DDPP is a simple procedure and the optimal treatment choice to reduce the risk of developing POPF after this extensive surgery.
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Affiliation(s)
- Teiichi Sugiura
- From the Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Katsuhiko Uesaka
- From the Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Ryo Ashida
- From the Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Katsuhisa Ohgi
- From the Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yukiyasu Okamura
- From the Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Mihoko Yamada
- From the Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Shimpei Otsuka
- From the Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
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Fancellu A, Sanna V, Deiana G, Ninniri C, Turilli D, Perra T, Porcu A. Current role of hepatopancreatoduodenectomy for the management of gallbladder cancer and extrahepatic cholangiocarcinoma: A systematic review. World J Gastrointest Oncol 2021; 13:625-637. [PMID: 34163578 PMCID: PMC8204357 DOI: 10.4251/wjgo.v13.i6.625] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/03/2021] [Accepted: 05/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hepatopancreatoduodenectomy (HPD) is the simultaneous combination of hepatic resection, pancreaticoduodenectomy, and resection of the entire extrahepatic biliary system. HPD is not a universally accepted due to high mortality and morbidity rates, as well as to controversial survival benefits. AIM To evaluate the current role of HPD for curative treatment of gallbladder cancer (GC) or extrahepatic cholangiocarcinoma (ECC) invading both the hepatic hilum and the intrapancreatic common bile duct. METHODS A systematic literature search using the PubMed, Web of Science, and Scopus databases was performed to identify studies reporting on HPD, using the following keywords: 'Hepatopancreaticoduodenectomy', 'hepatopancreatoduodenectomy', 'hepatopancreatectomy', 'pancreaticoduodenectomy', 'hepatectomy', 'hepatic resection', 'liver resection', 'Whipple procedure', 'bile duct cancer', 'gallbladder cancer', and 'cholangiocarcinoma'. RESULTS This updated systematic review, focusing on 13 papers published between 2015 and 2020, found that rates of morbidity for HPD have remained high, ranging between 37.0% and 97.4%, while liver failure and pancreatic fistula are the most serious complications. However, perioperative mortality for HPD has decreased compared to initial experiences, and varies between 0% and 26%, although in selected center it is well below 10%. Long term survival outcomes can be achieved in selected patients with R0 resection, although 5-year survival is better for ECC than GC. CONCLUSION The present review supports the role of HPD in patients with GC and ECC with horizontal spread involving the hepatic hilum and the intrapancreatic bile duct, provided that it is performed in centers with high experience in hepatobiliary-pancreatic surgery. Extensive use of preoperative portal vein embolization, and preoperative biliary drainage in patients with obstructive jaundice, represent strategies for decreasing the occurrence and severity of postoperative complications. It is advisable to develop internationally-accepted protocols for patient selection, preoperative assessment, operative technique, and perioperative care, in order to better define which patients would benefit from HPD.
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Affiliation(s)
- Alessandro Fancellu
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari 07100, Italy
| | | | - Giulia Deiana
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari 07100, Italy
| | - Chiara Ninniri
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari 07100, Italy
| | | | - Teresa Perra
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari 07100, Italy
| | - Alberto Porcu
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari 07100, Italy
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Endo I, Hirahara N, Miyata H, Yamamoto H, Matsuyama R, Kumamoto T, Homma Y, Mori M, Seto Y, Wakabayashi G, Kitagawa Y, Miura F, Kokudo N, Kosuge T, Nagino M, Horiguchi A, Hirano S, Yamaue H, Yamamoto M, Miyazaki M. Mortality, morbidity, and failure to rescue in hepatopancreatoduodenectomy: An analysis of patients registered in the National Clinical Database in Japan. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 28:305-316. [DOI: 10.1002/jhbp.918] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 01/11/2021] [Accepted: 02/18/2021] [Indexed: 12/14/2022]
Affiliation(s)
- Itaru Endo
- Japanese Society of Hepato‐Biliary‐Pancreatic Surgery Tokyo Japan
| | | | - Hiroaki Miyata
- Department of Healthcare Quality Assessment University of Tokyo Japan
| | - Hiroyuki Yamamoto
- Department of Healthcare Quality Assessment University of Tokyo Japan
| | - Ryusei Matsuyama
- Department of Gastroenterological Surgery Yokohama City University Yokohama Japan
| | - Takafumi Kumamoto
- Department of Gastroenterological Surgery Yokohama City University Yokohama Japan
| | - Yuki Homma
- Department of Gastroenterological Surgery Yokohama City University Yokohama Japan
| | - Masaki Mori
- The Japanese Society of Gastroenterological Surgery Tokyo Japan
| | - Yasuyuki Seto
- The Japanese Society of Gastroenterological Surgery Tokyo Japan
| | - Go Wakabayashi
- The Japanese Society of Gastroenterological Surgery Tokyo Japan
| | - Yuko Kitagawa
- The Japanese Society of Gastroenterological Surgery Tokyo Japan
| | - Fumihiko Miura
- Japanese Society of Hepato‐Biliary‐Pancreatic Surgery Tokyo Japan
| | - Norihiro Kokudo
- Japanese Society of Hepato‐Biliary‐Pancreatic Surgery Tokyo Japan
| | - Tomoo Kosuge
- Japanese Society of Hepato‐Biliary‐Pancreatic Surgery Tokyo Japan
| | - Masato Nagino
- Japanese Society of Hepato‐Biliary‐Pancreatic Surgery Tokyo Japan
| | | | - Satoshi Hirano
- Japanese Society of Hepato‐Biliary‐Pancreatic Surgery Tokyo Japan
| | - Hiroki Yamaue
- Japanese Society of Hepato‐Biliary‐Pancreatic Surgery Tokyo Japan
| | | | - Masaru Miyazaki
- Japanese Society of Hepato‐Biliary‐Pancreatic Surgery Tokyo Japan
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8
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Fong ZV, Brownlee SA, Qadan M, Tanabe KK. The Clinical Management of Cholangiocarcinoma in the United States and Europe: A Comprehensive and Evidence-Based Comparison of Guidelines. Ann Surg Oncol 2021; 28:2660-2674. [PMID: 33646431 DOI: 10.1245/s10434-021-09671-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 01/18/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND The incidence of cholangiocarcinoma has doubled over the last 15 years with a similar rise in mortality, which provides the impetus for standardization of evidence-based care through the establishment of guidelines. METHODS We compared available guidelines on the clinical management of cholangiocarcinoma in the United States and Europe, which included the National Comprehensive Cancer Network (NCCN), European Society for Medical Oncology (ESMO), British Society of Gastroenterology (BSG) and the International Liver Cancer Association (ILCA) guidelines. RESULTS There is discordance in the recommendation for biopsy in patients with potentially resectable cholangiocarcinoma and in the recommendation for use of fluorodeoxyglucose positron emission tomography scans. Similarly, the recommendation for preoperative biliary drainage for extrahepatic and perihilar cholangiocarcinoma in the setting of jaundice is inconsistent across all four guidelines. The BILCAP (capecitabine) and ABC-02 trials (gemcitabine with cisplatin) have provided the strongest evidence for systemic therapy in the adjuvant and palliative settings, respectively, but all guidelines have refrained from setting them as standard of care, given heterogeneity in the study cohorts and ABC-02's negative intention-to-treat results. CONCLUSIONS Future progress in enhancing survivorship of patients with cholangiocarcinoma would likely entail improvements in diagnostic biomarkers and novel systemic therapies. Based on recent results from studies of targeted therapy, future iterations of the guidelines will likely incorporate molecular profiling.
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Affiliation(s)
- Zhi Ven Fong
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah A Brownlee
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Motaz Qadan
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kenneth K Tanabe
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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9
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Aggressive Surgical Management of Gallbladder Cancer: Long-Term Results From a Retrospective Study of 315 Chinese Patients. Int Surg 2021. [DOI: 10.9738/intsurg-d-15-00328.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective
To investigate the best surgical treatment for the gallbladder cancer patient.
Summary of Background Data
Until now, aggressive surgery for advanced gallbladder cancer has been controversial. In this study, we analyzed gallbladder cancer patients' data retrospectively to find out which is the best surgical treatment for the patient.
Methods
From 2009 to 2013, 315 cases of gallbladder carcinoma were identified. Data were analyzed retrospectively. The review included analysis of survival rate, postoperative complications, operative mortality rate, and correlation between local extent of the primary tumor and frequency of nodal metastases.
Results
Postoperative complications occurred in 15 patients (6.2%). A total of 3% of patients who underwent a radical surgery procedure had complications, but in the extended radical surgery group, it was 9.8%. Operative mortality rate was 4.94%. No lymph node metastases were found in patients with T1 tumors. Nodal involvement in patients with T3 (55.22%) and T4 (82.50%) tumors was significantly higher than that in patients with T2 tumors (44.12%). In patients with stages I and II cancers, the radical resection group had a better survival rate than the simple cholecystectomy group. In patients with stage III cancer, the extended radical surgery group and radical surgery group showed better survival rates than others. In patients with stage IV cancer, the extended radical surgery group showed a 4% survival rate at 2 years, but others group had a 0% survival rate.
Conclusions
Simple cholecystectomy may decrease the long survival rates in patients with stages I and II cancer. In more advanced stages, extended radical resection should be performed if R0 resections can be achieved.
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10
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Nagino M, Hirano S, Yoshitomi H, Aoki T, Uesaka K, Unno M, Ebata T, Konishi M, Sano K, Shimada K, Shimizu H, Higuchi R, Wakai T, Isayama H, Okusaka T, Tsuyuguchi T, Hirooka Y, Furuse J, Maguchi H, Suzuki K, Yamazaki H, Kijima H, Yanagisawa A, Yoshida M, Yokoyama Y, Mizuno T, Endo I. Clinical practice guidelines for the management of biliary tract cancers 2019: The 3rd English edition. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 28:26-54. [PMID: 33259690 DOI: 10.1002/jhbp.870] [Citation(s) in RCA: 123] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/18/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The Japanese Society of Hepato-Biliary-Pancreatic Surgery launched the clinical practice guidelines for the management of biliary tract cancers (cholangiocarcinoma, gallbladder cancer, and ampullary cancer) in 2007, then published the 2nd version in 2014. METHODS In this 3rd version, clinical questions (CQs) were proposed on six topics. The recommendation, grade for recommendation, and statement for each CQ were discussed and finalized by an evidence-based approach. Recommendations were graded as Grade 1 (strong) or Grade 2 (weak) according to the concepts of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. RESULTS The 31 CQs covered the six topics: (a) prophylactic treatment, (b) diagnosis, (c) biliary drainage, (d) surgical treatment, (e) chemotherapy, and (f) radiation therapy. In the 31 CQs, 14 recommendations were rated strong and 14 recommendations weak. The remaining three CQs had no recommendation. Each CQ includes a statement of how the recommendations were graded. CONCLUSIONS This latest guideline provides recommendations for important clinical aspects based on evidence. Future collaboration with the cancer registry will be key for assessing the guidelines and establishing new evidence.
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Affiliation(s)
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Hideyuki Yoshitomi
- Department of Surgery, Saitama Medical Center, Dokkyo Medical University, Koshigaya, Japan
| | - Taku Aoki
- Second Department of Surgery, Dokkyo Medical University, Mibu, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Nagaizumi, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomoki Ebata
- Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masaru Konishi
- Department of Hepatobiliary Pancreatic Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Keiji Sano
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Kazuaki Shimada
- Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroaki Shimizu
- Department of Surgery, Teikyo University Chiba Medical Center, Ichihara, Japan
| | - Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Toshifumi Wakai
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Takuji Okusaka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Toshio Tsuyuguchi
- Department of Gastroenterology, Chiba Prefectural Sawara Hospital, Sawara, Japan
| | - Yoshiki Hirooka
- Department of Gastroenterology and Gastroenterological Oncology, Fujita Health University, Toyoake, Japan
| | - Junji Furuse
- Department of Medical Oncology, Faculty of Medicine, Kyorin University, Mitaka, Japan
| | - Hiroyuki Maguchi
- Education and Research Center, Teine-Keijinkai Hospital, Sapporo, Japan
| | - Kojiro Suzuki
- Department of Radiology, Aichi Medical University, Nagakute, Japan
| | - Hideya Yamazaki
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroshi Kijima
- Department of Pathology and Bioscience, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Akio Yanagisawa
- Department of Pathology, Japanese Red Cross Kyoto Diichi Hospital, Kyoto, Japan
| | - Masahiro Yoshida
- Department of Hepato-Biliary-Pancreatic & Gastrointestinal Surgery, International University of Health and Welfare, Ichikawa, Japan
| | - Yukihiro Yokoyama
- Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takashi Mizuno
- Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
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11
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Shimizu A, Motoyama H, Kubota K, Notake T, Fukushima K, Ikehara T, Hayashi H, Yasukawa K, Kobayashi A, Soejima Y. Safety and Oncological Benefit of Hepatopancreatoduodenectomy for Advanced Extrahepatic Cholangiocarcinoma with Horizontal Tumor Spread: Shinshu University Experience. Ann Surg Oncol 2020; 28:2012-2025. [PMID: 33044629 DOI: 10.1245/s10434-020-09209-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 09/19/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Although hepatopancreatoduodenectomy (HPD) is the only means of achieving R0 resection of widespread extrahepatic cholangiocarcinoma, its safety and oncological benefit remain controversial because of its inherent high risk of mortality and morbidity. OBJECTIVE The aim of this study was to retrospectively analyze short- and long-term outcomes and evaluate the safety and oncological benefit of this advanced procedure. METHODS The study cohort comprised 37 consecutive patients who had undergone major HPD. Portal vein embolization was performed before surgery in 20 (54%) patients with future remnant liver volume < 35%. RESULTS The median operative time and blood loss were 866 min and 1000 mL, respectively. Concomitant vascular resection was performed in five patients (14%). The overall morbidity and mortality rates were 100% and 5.4% (n = 2), respectively. Nineteen patients (51%) had major (Clavien-Dindo grade III or higher) complications, the most common being intra-abdominal infection (49%) and post-hepatectomy liver failure (46%, grade B/C: 32%/5%), followed by postoperative pancreatic fistula (30%, grade B/C). R0 resection was achieved in 31 patients (84%). The 1-, 3-, and 5-year overall survival (OS) rates were 83%, 48%, and 37%, respectively. In patients with R0 resection, 5-year OS was comparable between patients who had undergone major HPD and major hepatectomy alone (41% vs. 40%, p = non-significant). CONCLUSIONS HPD is a valid treatment option for extensive cholangiocarcinoma, offering long-term survival benefit at the cost of relatively high but acceptable morbidity and mortality rates. HPD is advocated in selected patients provided that it is considered possible to achieve R0 resection.
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Affiliation(s)
- Akira Shimizu
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan.
| | - Hiroaki Motoyama
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Koji Kubota
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tsuyoshi Notake
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kentaro Fukushima
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tomohiko Ikehara
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hikaru Hayashi
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Koya Yasukawa
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Akira Kobayashi
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yuji Soejima
- Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
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12
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Torres OJM, Alikhanov R, Li J, Serrablo A, Chan AC, de Souza M Fernandes E. Extended liver surgery for gallbladder cancer revisited: Is there a role for hepatopancreatoduodenectomy? Int J Surg 2020; 82S:82-86. [PMID: 32535266 DOI: 10.1016/j.ijsu.2020.05.085] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 05/19/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023]
Abstract
Gallbladder cancer (GBCA) is a rare and fatal disease and the majority of patients presents with advanced stage. Surgical resection associated with lymphadenectomy is the only chance for cure. For patients in stages III and IV, extended resection is the only treatment to achieve R0 margins. For GBCA invading the hepatoduodenal ligament and pancreatoduodenal region, the resection of extrahepatic bile duct and pancreas is necessary. Hepatopancreatoduodenectomy (HPD) represents the most complex and challenging procedure in the hepatopancreatobiliary region. Kuno at the Cancer Institute Hospital Tokyo performed the first HPD in Japan in 1974 and in 1980 Takasaki presented five cases and the 30-day mortality was 60%. After that, other countries started to perform the procedure including United States and Brazil. The main complications are liver failure and pancreatic fistula. Advancements in perioperative care, surgical technique, medical instruments and postoperative at intensive care unit have resulted in reduction in morbidity and mortality. The use of portal vein embolization is indicated to increase the liver volume in patients with insufficient remnant. Preoperative biliary drainage can prevent cholangitis and improve hepatic function. This procedure should be recommended before extended HPD in jaundiced patients. Operative results with mortality rates below 5% at high volume centers suggest that HPD should be performed at centers with expertise in hepatopancreatobiliary surgery.
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Affiliation(s)
- Orlando Jorge M Torres
- Full Professor and Chairman, Department of Hepatopancreatobiliary Surgery - Maranhão Federal University, Brazil.
| | - Ruslan Alikhanov
- Department of Hepatobiliary Surgery - Moscow Clinical Scientific Center, Russia
| | - Jun Li
- Department of Hepatobiliary Surgery and Visceral Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alejandro Serrablo
- Hepatobiliopancreatic Surgery Unit, General and Digestive Surgery Service, Hospital Miguel Servet, Zaragoza, Spain
| | - Albert C Chan
- Division of Liver Transplantation, The University of Hong Kong, HKSAR, China
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13
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D'Souza MA, Valdimarsson VT, Campagnaro T, Cauchy F, Chatzizacharias NA, D'Hondt M, Dasari B, Ferrero A, Franken LC, Fusai G, Guglielmi A, Hagendoorn J, Hidalgo Salinas C, Hoogwater FJH, Jorba R, Karanjia N, Knoefel WT, Kron P, Lahiri R, Langella S, Le Roy B, Lehwald-Tywuschik N, Lesurtel M, Li J, Lodge JPA, Martinou E, Molenaar IQ, Nikov A, Poves I, Rassam F, Russolillo N, Soubrane O, Stättner S, van Dam RM, van Gulik TM, Serrablo A, Gallagher TM, Sturesson C. Hepatopancreatoduodenectomy -a controversial treatment for bile duct and gallbladder cancer from a European perspective. HPB (Oxford) 2020; 22:1339-1348. [PMID: 31899044 DOI: 10.1016/j.hpb.2019.12.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 11/22/2019] [Accepted: 12/09/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Hepatopancreatoduodenectomy (HPD) is an aggressive operation for treatment of advanced bile duct and gallbladder cancer associated with high perioperative morbidity and mortality, and uncertain oncological benefit in terms of survival. Few reports on HPD from Western centers exist. The purpose of this study was to evaluate safety and efficacy for HPD in European centers. METHOD Members of the European-African HepatoPancreatoBiliary Association were invited to report all consecutive patients operated with HPD for bile duct or gallbladder cancer between January 2003 and January 2018. The patient and tumor characteristics, perioperative and survival outcomes were analyzed. RESULTS In total, 66 patients from 19 European centers were included in the analysis. 90-day mortality rate was 17% and 13% for bile duct and gallbladder cancer respectively. All factors predictive of perioperative mortality were patient and disease-specific. The three-year overall survival excluding 90-day mortality was 80% for bile duct and 30% for gallbladder cancer (P = 0.013). In multivariable analysis R0-resection had a significant impact on overall survival. CONCLUSION HPD, although being associated with substantial perioperative mortality, can offer a survival benefit in patient subgroups with bile duct cancer and gallbladder cancer. To achieve negative resection margins is paramount for an improved survival outcome.
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Affiliation(s)
- Melroy A D'Souza
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Valentinus T Valdimarsson
- Department of Clinical Sciences Lund, Surgery, Lund University, Skane University Hospital, Lund, Sweden
| | - Tommaso Campagnaro
- Department of Surgery, General and Hepatobiliary Surgery Unit, Verona University Hospital, Verona, Italy
| | - Francois Cauchy
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
| | - Nikolaos A Chatzizacharias
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Mathieu D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, AZ Groeninge Kortrijk, Belgium
| | - Bobby Dasari
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Alessandro Ferrero
- Department of HPB and Digestive Surgery, Ospedale Mauriziano Umberto I, Turin, Italy
| | - Lotte C Franken
- Department of Surgery, Amsterdam University Medical Centres, location AMC, Amsterdam, the Netherlands
| | - Giuseppe Fusai
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, NHS Foundation Trust, London, United Kingdom
| | - Alfredo Guglielmi
- Department of Surgery, General and Hepatobiliary Surgery Unit, Verona University Hospital, Verona, Italy
| | - Jeroen Hagendoorn
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Camila Hidalgo Salinas
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, NHS Foundation Trust, London, United Kingdom
| | - Frederik J H Hoogwater
- Department of Surgery, Division of Hepatopancreatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Rosa Jorba
- Hepatobiliary and Pancreatic Surgery Unit, General Surgery Department, Joan XXIII University Hospital, Tarragona, Spain
| | - Nariman Karanjia
- Surrey and Sussex Regional HPB Unit, Royal Surrey County Hospital, Guildford, United Kingdom
| | - Wolfram T Knoefel
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Düsseldorf, Düsseldorf, Germany
| | - Philipp Kron
- Department of Hepatobiliary Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Rajiv Lahiri
- Surrey and Sussex Regional HPB Unit, Royal Surrey County Hospital, Guildford, United Kingdom
| | - Serena Langella
- Department of HPB and Digestive Surgery, Ospedale Mauriziano Umberto I, Turin, Italy
| | - Bertrand Le Roy
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
| | - Nadja Lehwald-Tywuschik
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Düsseldorf, Düsseldorf, Germany
| | - Mickael Lesurtel
- Department of Surgery and Liver Transplantation, Croix-Rousse University Hospital, University of Lyon, Lyon, France
| | - Jun Li
- Department of Hepatobiliary Surgery and Visceral Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J Peter A Lodge
- Department of Hepatobiliary Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Erini Martinou
- Surrey and Sussex Regional HPB Unit, Royal Surrey County Hospital, Guildford, United Kingdom
| | - Izaak Q Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Andrej Nikov
- Department of Surgery, 2 Faculty of Medicine, Charles University and Central Military Hospital, Prague, 16002, Czech Republic
| | - Ignasi Poves
- Department of Surgery, Hospital del Mar, Barcelona, Spain
| | - Fadi Rassam
- Department of Surgery, Amsterdam University Medical Centres, location AMC, Amsterdam, the Netherlands
| | - Nadia Russolillo
- Department of HPB and Digestive Surgery, Ospedale Mauriziano Umberto I, Turin, Italy
| | - Olivier Soubrane
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
| | - Stefan Stättner
- Department of Visceral, Transplantation and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Amsterdam University Medical Centres, location AMC, Amsterdam, the Netherlands
| | - Alejandro Serrablo
- Hepatobiliopancreatic Surgery Unit, General and Digestive Surgery Service, Hospital Miguel Servet, Zaragoza, Spain
| | - Tom M Gallagher
- Department of Hepatobiliary and Transplant Surgery St Vincent's University Hospital Elm Park, Dublin, Ireland
| | - Christian Sturesson
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden.
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14
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Welch JC, Gleeson EM, Karachristos A, Pitt HA. Hepatopancreatoduodenectomy in North America: are the outcomes acceptable? HPB (Oxford) 2020; 22:360-367. [PMID: 31519357 DOI: 10.1016/j.hpb.2019.08.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 08/15/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatopancreatoduodenectomies (HPD) are historically associated with high morbidity and mortality. Currently, no data with hepatopancreatobiliary-specific complications have been available for HPD in North America. The aim of this retrospective analysis was to compare the outcomes of HPD to those of major hepatectomy (MH) and pancreatoduodenectomy (PD) in North America. METHODS The 2014-16 American College of Surgeons-National Surgical Quality Improvement Program database was queried for MH, PD, and HPD. Partial hepatectomies, wedge liver biopsies, distal pancreatectomies, pancreatic enucleations and total pancreatectomies were excluded. Propensity score matching was utilized to match 23 HPDs to 92 MHs and 138 PDs by 28 demographic, comorbidity, laboratory, operative and pathologic variables. Outcomes were compared among these three groups. RESULTS The overall morbidity and mortality for HPD were 87% and 26%, respectively, and were significantly higher (p < 0.01) compared to both MH (51%, 7.6%) and PD (52%, 1.4%). Post-hepatectomy liver failure (PHLF) was more common (p < 0.01) in HPD patients, but pancreatic fistula rates were similar. CONCLUSION The morbidity and mortality after HPD are significantly higher than after MH or PD alone and may explain why HPD is performed so infrequently in North America. Centralization of HPD to a very few centers may be a strategy to improve outcomes.
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Affiliation(s)
- Jonathan C Welch
- Lewis Katz School of Medicine at Temple University, 3500 N. Broad St., Philadelphia, PA, 19140, USA
| | - Elizabeth M Gleeson
- Department of Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1259, New York, NY, 10029, USA
| | - Andreas Karachristos
- Department of Surgery, University of South Florida, 2 Tampa General Circle 7th Floor, Tampa, FL, 33606, USA
| | - Henry A Pitt
- Lewis Katz School of Medicine at Temple University, 3509 N. Broad St., Boyer Pavilion, E938, Philadelphia, PA 1914, USA.
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15
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Nagino M. Fifty-year history of biliary surgery. Ann Gastroenterol Surg 2019; 3:598-605. [PMID: 31788648 PMCID: PMC6875948 DOI: 10.1002/ags3.12289] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 08/19/2019] [Accepted: 08/22/2019] [Indexed: 12/14/2022] Open
Abstract
There has been enormous progress in the surgical treatment of biliary tract cancers in the past 50 years. In preoperative management, biliary drainage methods have changed from percutaneous transhepatic biliary drainage to endoscopic nasobiliary drainage, while the advent of multidetector-row computed tomography in imaging diagnostics now enables visualization of three-dimensional anatomy, extent of cancer progression, and hepatic segment volume. Portal vein embolization has also greatly improved the safety of extended hepatectomy, and indication of extended hepatectomy can now be objectively determined with a combination of the indocyanine green test and computed tomography volumetry. In terms of surgery, combined resection and reconstruction of the portal vein and/or hepatic artery can now be safely carried out at specialized centers. Further, long-term survival can be attained with combined vascular resection if R0 resection can be achieved, even in locally advanced cancer. Hepatopancreatoduodenectomy, combined major hepatectomy with pancreatoduodenectomy, should be aggressively carried out for laterally advanced cholangiocarcinoma, whereas its indication for advanced gallbladder cancer should be carefully evaluated. Japanese surgeons have made a significant contribution to the progression of extended surgeries such as combined vascular resection and hepatopancreatoduodenectomy for biliary tract cancer.
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Affiliation(s)
- Masato Nagino
- Division of Surgical OncologyDepartment of SurgeryNagoya University Graduate School of MedicineNagoyaJapan
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16
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Mizuno T, Ebata T, Yokoyama Y, Igami T, Yamaguchi J, Onoe S, Watanabe N, Ando M, Nagino M. Major hepatectomy with or without pancreatoduodenectomy for advanced gallbladder cancer. Br J Surg 2019; 106:626-635. [PMID: 30762874 DOI: 10.1002/bjs.11088] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 11/16/2018] [Accepted: 11/22/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND The indications for major hepatectomy for gallbladder cancer either with or without pancreatoduodenectomy remain controversial. The clinical value of these extended procedures was evaluated in this study. METHODS Patients who underwent major hepatectomy for gallbladder cancer between 1996 and 2016 were identified from a prospectively compiled database. Postoperative outcomes and overall survival were compared between patients undergoing major hepatectomy alone or combined with pancreatoduodenectomy (HPD). RESULTS Seventy-nine patients underwent major hepatectomy alone and 38 patients had HPD. The patients who underwent HPD were more likely to have T4 disease (P < 0·001), nodal metastasis (P = 0·015) and periaortic nodal metastasis (P = 0·006), but were less likely to receive adjuvant therapy (P = 0·006). HPD was associated with a high incidence of grade III or higher complications (P = 0·002) and death (P = 0·037). Overall survival was longer in patients who underwent major hepatectomy alone than in patients who underwent HPD (median survival time 32 versus 10 months; P < 0·001). In multivariable analysis, surgery in the early period (1996-2006) (P = 0·002), pathological T4 disease (P = 0·005) and distant metastasis (P < 0·001) were associated with shorter overall survival, and cystic duct tumour (P = 0·002) with longer overall survival. CONCLUSION Major hepatectomy alone for gallbladder cancer contributes to favourable overall survival with low morbidity and mortality, whereas HPD is associated with poor overall survival and high morbidity and mortality rates. HPD may eradicate locally spreading gallbladder cancer; however, the indication for the procedure is questioned from an oncological viewpoint.
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Affiliation(s)
- T Mizuno
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - T Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Y Yokoyama
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - T Igami
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - J Yamaguchi
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - S Onoe
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - N Watanabe
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - M Ando
- Data Coordinating Centre, Department of Advanced Medicine, Nagoya University Hospital, Nagoya, Japan
| | - M Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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17
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Lee EC, Han SS, Lee SD, Park SJ. Is Hepatopancreatoduodenectomy an Acceptable Operation for Biliary Cancer?. Am Surg 2018. [DOI: 10.1177/000313481808400523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Hepatopancreatoduodenectomy (HPD) is usually indicated for the resection of locally advanced bile duct (BD) cancer or gallbladder (GB) cancer. Previous studies have demonstrated a favorable survival rate in BD cancer patients after HPD if R0 resection is achieved. By contrast, the benefit of HPD for GB cancer remains controversial. This study aimed to analyze the outcomes of GB and BD cancer after HPD. Between January 2004 and December 2013, a total of 22 patients underwent HPD for BD (n = 14) or GB cancer (n = 8). We analyzed the survival, mortality, morbidity, and prognostic factors. After HPD, the mortality rate was 4.5 per cent and the morbidity rate was 68.2 per cent. Pancreatic fistula occurred in 50.0 per cent of the patients (grade A, 40.9%; grade B, 9.1%). Liver failure did not occur. The 1-, 3-, and 5-year survival rates for BD cancer patients were 57.1, 17.9, and 17.9 per cent and those for GB cancer patients were 62.5, 25.0, and 25.0 per cent, respectively ( P = 0.768). In BD cancer, significant prognostic factors were tumor size, portal vein invasion, multiple lymph node metastases, and operation time. Furthermore, BD cancer patients with three or more of risk factors showed poorer survival than those with fewer than three risk factors. HPD for GB and BD cancer can be performed with acceptable mortality and morbidity rates. GB cancer patients who underwent HPD showed comparable survival rates compared with BD cancer patients. Long-term survival can be achieved in selected patients with BD cancer.
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Affiliation(s)
- Eung Chang Lee
- Center for Liver Cancer, National Cancer Center, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Sung-Sik Han
- Center for Liver Cancer, National Cancer Center, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Seung Duk Lee
- Center for Liver Cancer, National Cancer Center, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Sang-Jae Park
- Center for Liver Cancer, National Cancer Center, Goyang-si, Gyeonggi-do, Republic of Korea
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18
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Aoki T, Sakamoto Y, Kohno Y, Akamatsu N, Kaneko J, Sugawara Y, Hasegawa K, Makuuchi M, Kokudo N. Hepatopancreaticoduodenectomy for Biliary Cancer: Strategies for Near-zero Operative Mortality and Acceptable Long-term Outcome. Ann Surg 2018; 267:332-337. [PMID: 27811506 DOI: 10.1097/sla.0000000000002059] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the safety and efficacy of hepatopancreaticoduodenectomy (HPD) for patients with biliary cancer. BACKGROUND HPD is thought to be the only curative treatment for widespread bile duct cancer and for some advanced cases of gallbladder cancer; however, HPD has not yet been accepted as a standard operative procedure because of concerns over morbidity and mortality. METHODS Fifty-two patients undergoing HPD were retrospectively reviewed. The patient and tumor characteristics, preoperative treatments, operative results, and survival outcomes were investigated. RESULTS Preoperative biliary drainage and portal vein embolization were applied for all patients undergoing right-sided HPD or a left trisectionectomy. A major hepatectomy was performed in 42 patients, and a 2-stage pancreaticojejunostomy was selected in all the cases. The 90-day mortality was 0; however, 1 patient died because of a liver abscess 230 days after surgery. Postoperative significant complications (grade III or greater) and liver insufficiency were observed in 19 (37%) and 2 (3.8%) patients, respectively, and no abdominal bleeding events after the formation of a pancreatic fistula were encountered. The 5-year overall survival rate was 44.5%, and a significant difference was not observed between patients with bile duct cancer and those with gallbladder cancer. The operative procedure was switched to an HPD in 13 patients based on intraoperative findings, and the recurrence-free survival rate for these patients was poorer than that for patients who did not require a switch in operative procedure (P = 0.004). CONCLUSIONS HPD can be safely performed using the presently reported surgical strategies with acceptable short and long-term outcomes. A precise assessment of the extent of tumor spread might improve patient outcome.
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Affiliation(s)
- Taku Aoki
- Hepato-Biliary-Pancreatic Surgery Division, Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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19
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Capobianco I, Rolinger J, Nadalin S. Resection for Klatskin tumors: technical complexities and results. Transl Gastroenterol Hepatol 2018; 3:69. [PMID: 30363698 PMCID: PMC6182019 DOI: 10.21037/tgh.2018.09.01] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 08/27/2018] [Indexed: 12/18/2022] Open
Abstract
Klatskin's tumors, actually-redefined as perihilar cholangiocarcinoma (phCCA) do represent 50-70% of all CCAs and develop in a context of chronic inflammation and cholestasis of bile ducts. Surgical resection provides the only chance of cure for this disease but is technically challenging because of the complex, intimate and variable relationship between biliary and vascular structures at this location. Five years survival rates range between 25-45% (median 27-58 months) in case of R0 resection and 0-23% (median 12-21 months) in case of R1 resection respectively. It should be noted that the major costs of high radicality are represented by relative high morbidity and mortality rates (i.e., 20-66% and 0-9% respectively). Considering the fact that radical resection may represent the only curative treatment of phCCA, we focused our review on surgical planning and techniques that may improve resectability rates and outcomes for locally advanced phCCA. The surgical treatment of phCCA can be successful when following aspects have been fulfilled: (I) accurate preoperative diagnostic aimed to identify the tumor in all its details (localization and extension) and to study all the risk factors influencing a posthepatectomy liver failure (PHLF): i.e., liver volume, liver function, liver quality, haemodynamics and patient characteristics; (II) High end surgical skills taking in consideration the local extension of the tumor and the vascular invasion which usually require an extended hepatic resection and often a vascular resection; (III) adequate postoperative management aimed to avoid major complications (i.e., PHLF and biliary complications). These are technically challenging operations and must be performed in a high volume centres by hepato-biliary-pancreas (HBP)-surgeons with experience in microsurgical vascular techniques.
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Affiliation(s)
- Ivan Capobianco
- Department of General, Visceral and Transplant Surgery, University Hospital Tuebingen, Tuebingen, Germany
| | - Jens Rolinger
- Department of General, Visceral and Transplant Surgery, University Hospital Tuebingen, Tuebingen, Germany
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, University Hospital Tuebingen, Tuebingen, Germany
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Wang J, Zhang ZG, Zhang WG. A modified surgical approach of hepatopancreatoduodenectomy for advanced gallbladder cancer: Report of two cases and literature review. Curr Med Sci 2017; 37:855-860. [PMID: 29270743 DOI: 10.1007/s11596-017-1817-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 05/12/2017] [Indexed: 02/07/2023]
Abstract
Gallbladder cancer (GBC) is the most common cancer of the biliary tract, constituting 80%-95% of malignant biliary tract tumors. Surgical resection is currently regarded as the sole curative treatment for GBC. Hepatopancreatoduodenectomy (HPD) has been adopted to remove the advanced gallbladder tumor together with the infiltrated parts within the liver, lower biliary tract and the peripancreatic region of GBC patients. However, patients who underwent HPD were reported to have a distinctly higher postoperative morbidity (71.4%, ranging from 30.8% to 100%) and mortality (13.2%, ranging from 2.4% to 46.9%) than those given pancreatoduodenectomy (PD) alone. We present two patients with advanced GBC who underwent a modified surgical approach of HPD: PD with microwave ablation (MWA) of adjacent liver tissues and the technique of intraductal cooling of major bile ducts. No serious complications like bile leakage, pancreatic fistula, hemorrhage and organ dysfunction, etc. occurred in the two patients. They had a rapid recovery with postoperative hospital stay being 14 days. Application of this approach effectively eliminated tumor-infiltrated adjacent tissues, and maximally reduced the postoperative morbidity and mortality. This modified surgical method is secure and efficacious for the treatment of locally advanced GBC.
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Affiliation(s)
- Jian Wang
- Department of Hepatic Surgery Centre, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Department of Hepatopancreatobiliary Surgery, Taihe Hospital, Hubei University of Medicine, Shiyan, 442000, China
| | - Zhan-Guo Zhang
- Department of Hepatic Surgery Centre, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Wan-Guang Zhang
- Department of Hepatic Surgery Centre, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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Chiba N, Gunji T, Ozawa Y, Hikita K, Sano T, Tomita K, Abe Y, Kawachi S. Hepatopancreatoduodenectomy for perihilar cholangiocarcinoma following laparoscopic total gastrectomy. Int J Surg Case Rep 2017; 41:209-211. [PMID: 29096345 PMCID: PMC5686222 DOI: 10.1016/j.ijscr.2017.10.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 10/19/2017] [Accepted: 10/22/2017] [Indexed: 11/29/2022] Open
Abstract
Surgical resection is the only curative treatment for perihilar cholangiocarcinoma. Hepatopancreatoduodenectomy for biliary cancers after total gastrectomy is a challenging procedure with high morbidity and mortality rates. However, this procedure can provide the chance for long-term survival if curative resection is feasible. This case was the first report of hepatopancreatoduodenectomy following laparoscopic total gastrectomy. Introduction Surgical resection is the only curative treatment for perihilar cholangiocarcinoma. However, Hepatopancreatoduodenectomy (HPD) procedure remains controversial in regard to the balance between the survival benefit and high risk of mortality and morbidity. Presentation of case A 72-year-old man who was revealed the dilation of intrahepatic hepatic duct by computed tomography after laparoscopic total gastrectomy was referred to our hospital. The patient had undergone laparoscopic total gastrectomy with Roux-en-Y esophageal-jejunostomy reconstruction 1 year previously. By several examinations, we consequently diagnosed this case as a perihilar cholangiocarcinoma and performed HPD. Histological examination revealed a well differentiated adenocarcinoma without lymph-node metastasis and a negative margin of liver parenchyma and pancreas. He was recovered from a grade B pancreatic fistula by conservative therapy and discharged post-operatively on day 64 in good health. The patient received postoperative systemic chemotherapy with gemcitabine for 6 months. 16 months after surgery, the patient has had no recurrence. Discussion HPD for biliary and cancers after total gastrectomy is a challenging procedure with high morbidity and mortality rates. However, this procedure can provide the chance for long-term survival if curative resection is feasible. Conclusion This case was the first report of hepatopancreatoduodenectomy following laparoscopic total gastrectomy.
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Affiliation(s)
- Naokazu Chiba
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Japan.
| | - Takahiro Gunji
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Japan
| | - Yosuke Ozawa
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Japan
| | - Kosuke Hikita
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Japan
| | - Toru Sano
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Japan
| | - Koichi Tomita
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Japan
| | - Yuta Abe
- Department of Surgery, Keio University School of Medicine, Japan
| | - Shigeyuki Kawachi
- Department of Digestive and Transplantation Surgery, Tokyo Medical University Hachioji Medical Center, Japan
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Dai WC, Chok KS, Cheung TT, Chan AC, Chan SC, Lo CM. Hepatopancreatoduodenectomy for advanced hepatobiliary malignancies: a single-center experience. Hepatobiliary Pancreat Dis Int 2017; 16:382-386. [PMID: 28823368 DOI: 10.1016/s1499-3872(17)60039-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 12/16/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hepatopancreatoduodenectomy is a complicated and challenging procedure but necessary for curative resection for advanced hepatobiliary malignancies. This retrospective study was to examine the safety and survival outcomes of hepatopancreatoduodenectomy in our center. METHODS Prospectively collected data of 12 patients who underwent hepatopancreatoduodenectomy for advanced hepatobiliary malignancies in our hospital from January 1998 to December 2014 were analyzed. The primary endpoints are treatment-related morbidity and mortality and the secondary endpoints are overall survival and disease-free survival. RESULTS Curative resection was achieved in 11 (91.7%) patients. Complications developed in 10 (83.3%) patients. Three hospital deaths resulted from multiorgan failure secondary to postoperative pancreatic fistula or hepaticojejunostomy leakage. Six of the nine remaining patients had disease recurrence. The nine patients had a median survival of 39.8 (5.3-151.8) months. The 1-, 3- and 5-year overall survival rates were 66.7%, 55.6% and 27.8%, respectively. The corresponding disease-free survival rates were 55.6%, 44.4% and 29.6%, respectively. CONCLUSIONS Morbidity and mortality after hepatopancreatoduodenectomy were significant. With R0 resection, the 5-year overall survival and disease-free survival rates were 27.8% and 29.6%, respectively.
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Affiliation(s)
- Wing Chiu Dai
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China.
| | - Kenneth Sh Chok
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Tan To Cheung
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Albert Cy Chan
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - See Ching Chan
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
| | - Chung Mau Lo
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, 102 Pok Fu Lam Road, Hong Kong, China
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Fernandes EDSM, Mello FTD, Ribeiro-Filho J, Monte-Filho APD, Fernandes MM, Coelho RJ, Matos MC, Souza AAPD, Torres OJM. THE LARGEST WESTERN EXPERIENCE WITH HEPATOPANCREATODUODENECTOMY: LESSONS LEARNED WITH 35 CASES. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2017; 29:17-20. [PMID: 27120733 PMCID: PMC4851144 DOI: 10.1590/0102-6720201600010005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 12/10/2015] [Indexed: 01/04/2023]
Abstract
Background: Hepatopancreatoduodenectomy is one of the most complex abdominal operations mainly indicated in advanced biliary carcinoma. Aim: To present 10-year experience performing this operation in advanced malignant tumors. Methods: This is a retrospective descriptive study. From 2004 to 2014, 35 hepatopancreatoduodenectomies were performed in three different institutions. The most common indication was advanced biliary carcinoma in 24 patients (68.5%). Results: Eighteen patients had gallbladder cancer, eight Klatskin tumors, five neuroendocrine tumors with liver metastasis, one colorectal metastasis invading the pancreatic head, one intraductal papillary mucinous neoplasm with liver metastasis, one gastric cancer recurrence with liver involvement and one ocular melanoma with pancreatic head and right liver lobe metastasis. All patients were submitted to pancreatoduodenectomy with a liver resection as follows: eight right trisectionectomies, five right lobectomies, four left lobectomies, 18 central lobectomies (IVb, V and VIII). The overall mortality was 34.2% (12/35) and the overall morbidity rate was 97.4%. Conclusion: Very high mortality is seen when major liver resection is performed with pancreatoduodenectomy, including right lobectomy and trisectionectomy. Liver failure in combination with a pancreatic leak is invariably lethal. Efforts to ensure a remnant liver over 40-50% of the total liver volume are the key to obtain patient survival.
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Affiliation(s)
| | - Felipe Tavares de Mello
- Department of Surgery and Transplantation of Rio de Janeiro, Adventist Hospital, Rio de Janeiro, RJ, Brazil
| | - Joaquim Ribeiro-Filho
- Department of Surgery, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | | | - Romulo Juventino Coelho
- Department of Surgery and Transplantation of Rio de Janeiro, Adventist Hospital, Rio de Janeiro, RJ, Brazil
| | - Monique Couto Matos
- Department of Surgery and Transplantation of Rio de Janeiro, Adventist Hospital, Rio de Janeiro, RJ, Brazil
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Benzing C, Hau HM, Atanasov G, Broschewitz J, Krenzien F, Bartels M, Wiltberger G. Outcome and complications of combined liver and pancreas resections: a retrospective analysis. Acta Chir Belg 2016; 116:340-345. [PMID: 27471834 DOI: 10.1080/00015458.2016.1186962] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Combined resections of the liver and pancreas are related to high complication and mortality rates. The present study assessed the outcome of these procedures and identified specific risk factors for morbidity and mortality. METHODS Between January 2001 and April 2012, 28 combined liver/pancreas resections were performed at our institution. All patients were retrospectively analysed using a database with regards to baseline characteristics, surgical procedures, complications and survival. RESULTS Among the pancreatic resections, there were 12 (42.9%) Kausch-Whipple (KW), 9 (32.1%) pylorus-preserving pancreaticoduodenectomy (PPPD), 6 (21.4%) distal pancreatectomies (DP) and 1 (3.6%) total pancreaticoduodenectomy (TPD). In 12 (48.9%) cases, major complications (grade IIIb-V) were observed. Overall survival was 35 months (SD = 40.5) and the 3-year survival rate was 35.7% (1-year survival rate: 50%). DISCUSSION Combined resections of the liver and pancreas are associated with high complication rates, especially if major liver resections are performed. Therefore, it is mandatory to do a thorough evaluation of potential patients.
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Affiliation(s)
- Christian Benzing
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Hans-Michael Hau
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Georgi Atanasov
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Johannes Broschewitz
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Felix Krenzien
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Michael Bartels
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Georg Wiltberger
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Leipzig, Germany
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Fukami Y, Kaneoka Y, Maeda A, Takayama Y, Onoe S. Major hepatopancreatoduodenectomy with simultaneous resection of the hepatic artery for advanced biliary cancer. Langenbecks Arch Surg 2016; 401:471-8. [PMID: 27023217 DOI: 10.1007/s00423-016-1413-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 03/18/2016] [Indexed: 01/02/2023]
Abstract
BACKGROUND Major hepatopancreatoduodenectomy (HPD) with simultaneous resection of the hepatic artery (HA) for biliary cancer is the most extended surgery for obtaining curative resection, and its clinical significance is unclear. The aim of this study was to appraise the clinical value of this extended procedure as a treatment for biliary cancer. METHODS We retrospectively reviewed the medical records of 38 patients with biliary cancer who underwent major HPD from 1994 to 2014. Clinicopathological factors and survival following HPD were compared between patients with and without simultaneous resection of the HA. RESULTS Of the 38 study patients, 12 patients (32 %) underwent major HPD with HA. There was no significant difference in major complications between the two groups. The overall 2-year survival rate and the median survival time following major HPD with HA were 71 % and 42.3 months. The survival of the patients with gallbladder cancer was significantly worse than that of the patients with bile duct cancer (p = 0.001). CONCLUSIONS Major HPD with simultaneous resection of the HA can be a preferable treatment option for bile duct cancer that offers acceptable perioperative morbidity and mortality, as well as long-term survival. However, this procedure for gallbladder cancer should not be performed.
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Affiliation(s)
- Yasuyuki Fukami
- Department of Surgery, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, 503-8502, Japan.
| | - Yuji Kaneoka
- Department of Surgery, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, 503-8502, Japan
| | - Atsuyuki Maeda
- Department of Surgery, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, 503-8502, Japan
| | - Yuichi Takayama
- Department of Surgery, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, 503-8502, Japan
| | - Shunsuke Onoe
- Department of Surgery, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, 503-8502, Japan
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A systematic review of safety and efficacy of hepatopancreatoduodenectomy for biliary and gallbladder cancers. HPB (Oxford) 2016; 18:1-6. [PMID: 26776844 PMCID: PMC4750224 DOI: 10.1016/j.hpb.2015.07.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 07/27/2015] [Accepted: 07/29/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To review the evidence on the safety and efficacy of hepatopancreatoduodenectomy for biliary and gallbladder cancers. METHODS Medline and EMBASE were systematically searched for papers of hepatopancreatoduodenectomy in patients with biliary and gallbladder cancers. RESULTS Eighteen studies involving 397 patients were reviewed. Major hepatectomy was undertaken in 81.3% of the 397 patients and the R0 resection rate was 71.3%. The morbidity and mortality rates were 78.9% and 10.3%, respectively. The 5-year overall survival rate ranged from 3% to 50% (median = 31%). The 5-year survival rate in patients who underwent curative resection was 18-68.8% (median = 51.3%), and 0% in patients who received non-curative resection. CONCLUSIONS Hepatopancreatoduodenectomy is a challenging procedure with high morbidity and mortality rates. However, this procedure can provide a chance of long-term survival in patients in whom curative resection is feasible.
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Zhou Y, Zhang Z, Wu L, Li B. A systematic review of the safety and efficacy of hepatopancreatoduodenectomy for biliary and gallbladder cancers. HPB (Oxford) 2015:n/a-n/a. [PMID: 26507924 DOI: 10.1111/hpb.12511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 07/29/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To review the evidence on the safety and efficacy of hepatopancreatoduodenectomy for biliary and gallbladder cancers. METHODS Medline and EMBASE were systematically searched for papers describing hepatopancreatoduodenectomy in patients with biliary and gallbladder cancers. RESULTS Eighteen studies involving 397 patients were reviewed. A major hepatectomy was undertaken in 81.3% of the 397 patients, and the R0 resection rate was 71.3%. The morbidity and mortality rates were 78.9% and 10.3%, respectively. The 5-year overall survival rate ranged from 3% to 50% (median = 31%). The 5-year survival rate in patients who underwent a curative resection was 18-68.8% (median = 51.3%), and 0% in patients who received a non-curative resection. CONCLUSIONS A hepatopancreatoduodenectomy is a challenging procedure with high morbidity and mortality rates. However, this procedure can provide a chance of long-term survival in patients in whom a curative resection is feasible.
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Affiliation(s)
- Yanming Zhou
- Department of Hepatobiliary & Pancreatovascular Surgery, First affiliated Hospital of Xiamen University, Xiamen, China
| | - Zuobing Zhang
- Department of Hepatobiliary & Pancreatovascular Surgery, First affiliated Hospital of Xiamen University, Xiamen, China
| | - Lupeng Wu
- Department of Hepatobiliary & Pancreatovascular Surgery, First affiliated Hospital of Xiamen University, Xiamen, China
| | - Bin Li
- Department of Hepatobiliary & Pancreatovascular Surgery, First affiliated Hospital of Xiamen University, Xiamen, China
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Yamamoto Y, Sugiura T, Okamura Y, Ito T, Ashida R, Uemura S, Miyata T, Kato Y, Uesaka K. Is combined pancreatoduodenectomy for advanced gallbladder cancer justified? Surgery 2015; 159:810-20. [PMID: 26506566 DOI: 10.1016/j.surg.2015.09.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 08/23/2015] [Accepted: 09/12/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND The clinical impact of combined pancreatoduodenectomy (PD) for advanced gallbladder cancer remains unclear. METHODS A total of 96 patients who underwent resection for stage II, III, or IV gallbladder cancer were enrolled. Patients with lower bile duct involvement, pancreatic or duodenal infiltration, or peripancreatic lymph node metastasis were considered candidates for combined PD. The operative outcomes were compared between the patients treated with PD (PD group, n = 21) and those treated without PD (non-PD group, n = 75), and between those treated with major hepatopancreatoduodenectomy (major HPD group, n = 9) and those treated with major hepatectomy (major hepatectomy group, n = 20). RESULTS Overall morbidity in the PD group was greater than that in the non-PD group (81% vs 23%, P < .001), whereas the overall survival (OS) was comparable between the groups (5-year OS; 39.8% vs 46.7%, P = .96). There was no in-hospital mortality in the PD group. A serum albumin <3.0 g/dL (P = .004) and tumor size ≥ 9.0 cm (P = .029) were associated independently with a poor prognosis in the PD group. Overall morbidity in the major HPD group was greater than that in the major hepatectomy group (89% vs 40%, P = .014), whereas the OS was comparable between the groups (5-year OS; 34.6% vs 21.1%, P = .57), and the OS of major HPD group was better than that of unresectable group (n = 18, P = .017). CONCLUSION Combined PD, including major HPD, is beneficial for selected patients of advanced gallbladder cancer; however, the indications should be carefully evaluated because of greater morbidity rates.
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Affiliation(s)
- Yusuke Yamamoto
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan.
| | - Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yukiyasu Okamura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Takaaki Ito
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Ryo Ashida
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Sunao Uemura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Takashi Miyata
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yoshiyasu Kato
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
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Tran TB, Dua MM, Spain DA, Visser BC, Norton JA, Poultsides GA. Hepato-pancreatectomy: how morbid? Results from the national surgical quality improvement project. HPB (Oxford) 2015; 17:763-9. [PMID: 26058463 PMCID: PMC4557649 DOI: 10.1111/hpb.12426] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Accepted: 04/13/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Simultaneous resection of both the liver and the pancreas carries significant complexity. The objective of this study was to investigate peri-operative outcomes after a synchronous hepatectomy and pancreatectomy (SHP). METHODS The American College of Surgeons National Surgical Quality Improvement Project database was queried to identify patients who underwent SHP. Resections were categorized as '< hemihepatectomy', '≥ hemihepatectomy' (hemihepatectomy and trisectionectomy), 'PD' (pancreaticoduodenectomy and total pancreatectomy) and 'distal' (distal pancreatectomy and enucleation). RESULTS From 2005 to 2013, 480 patients underwent SHP. Patients were stratified based on the extent of resection: '< hemihepatectomy + distal (n = 224)', '≥ hemihepatectomy + distal' (n = 49), '< hemihepatectomy + PD' (n = 83) and '≥ hemihepatectomy + PD' (n = 24). Although the first three groups had a reasonable and comparable safety profile (morbidity 33-51% and mortality 0-6.6%), the '≥ hemihepatectomy + PD' group was associated with an 87.5% morbidity (organ space infection 58.3%, re-intubation 12.5%, reoperation 25% and septic shock 25%), 8.3% 30-day mortality and 18.2% in-hospital mortality. CONCLUSIONS A synchronous hemihepatectomy (or trisectionectomy) with PD remains a highly morbid combination and should be reserved for patients who have undergone extremely cautious selection.
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Affiliation(s)
- Thuy B Tran
- Department of Surgery, Stanford Cancer Institute, Stanford University, Stanford, CA, USA
| | - Monica M Dua
- Department of Surgery, Stanford Cancer Institute, Stanford University, Stanford, CA, USA
| | - David A Spain
- Department of Surgery, Stanford Cancer Institute, Stanford University, Stanford, CA, USA
| | - Brendan C Visser
- Department of Surgery, Stanford Cancer Institute, Stanford University, Stanford, CA, USA
| | - Jeffrey A Norton
- Department of Surgery, Stanford Cancer Institute, Stanford University, Stanford, CA, USA
| | - George A Poultsides
- Department of Surgery, Stanford Cancer Institute, Stanford University, Stanford, CA, USA
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Conrad C, Ogiso S, Inoue Y, Shivathirthan N, Gayet B. Laparoscopic parenchymal-sparing liver resection of lesions in the central segments: feasible, safe, and effective. Surg Endosc 2015; 29:2410-7. [PMID: 25391984 DOI: 10.1007/s00464-014-3924-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 09/26/2014] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Here we report the first systematic evaluation of laparoscopic parenchymal-sparing segmentectomies for the resection of lesions in the central liver segments and the first series of laparoscopic mesohepatectomies. PATIENTS AND METHODS From 1995 to 2012, 482 laparoscopic hepatectomies were performed. Thirty-two patients underwent isolated resection of IVa and VIII, bisegmentectomies of IVa/IVb and V/VIII, or mesohepatectomy. Sixteen isolated resections of IVb or V were excluded. Data was extracted from a retrolective database and chart review. Complications were classified (Clavien-Dindo) by three independent surgeons. Seventeen patients had colorectal liver metastasis, four had neuroendocrine tumors, five had hepatocellular carcinoma, two had GIST, and one each had esophageal cancer, breast cancer, and melanoma. Fifteen patients underwent anatomic- and 17 non-anatomic wedge resection. Average blood loss was 403 cc (SD 475), and overall operative time was 183 (SD 106) for hepatectomy and 253 min (SD 94) for mesohepatectomies. Major complications were mainly attributable to synchronous procedures. Mortality, transfusion, and morbidity rates were 0, 12, and 37 %, respectively. CONCLUSION Parenchymal-sparing laparoscopic central liver resections and mesohepatectomies are feasible, safe, and effective if specific technical details we have learned over time are considered. Concomitant procedures should be an exception. This approach exhibits an alternative to open surgery while avoiding unnecessary sacrifice of functional parenchyma.
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Affiliation(s)
- Claudius Conrad
- Department of Digestive Pathology, Institute Mutulatiste Montsouris, Paris Descartes University, Paris, France,
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de Santibañes M, Dietrich A, Busnelli VC, Pekolj J, Quintana GO, de Santibañes E. Associated liver and multivisceral resections: should we extend the frontiers of resectability? Updates Surg 2015; 67:11-7. [DOI: 10.1007/s13304-015-0280-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 01/26/2015] [Indexed: 01/16/2023]
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Mizuno T, Kanemoto H, Sugiura T, Okamura Y, Uesaka K. Central hepatectomy with pancreatoduodenectomy for diffusely spread bile duct cancer. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 22:287-93. [PMID: 25488828 DOI: 10.1002/jhbp.197] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Major hepatectomy with concomitant pancreatoduodenectomy (major-HPD) is the only procedure that provides a curative resection for diffusely spread extrahepatic bile duct cancer (DSEBDC). We sometimes encounter patients who cannot undergo major-HPD because of a poor functional hepatic reserve. The aim of the present study was to assess the feasibility of central hepatectomy with pancreatoduodenectomy (central-HPD) for patients with DSEBDC as an alternative to major-HPD. METHODS Between 2002 and 2010, six patients with DSEBDC underwent central-HPD. The hepatectomy procedures for central-HPD included central bisectionectomy with S1 resection (S1r) and right anterior sectionectomy with S1r. RESULTS The estimated resection liver volume was decreased from 77.5% to 46.6% by the application of central-HPD. The median operative duration was 929 min, and the median blood loss was 2568 ml. Postoperative complications were observed in five patients. The proximal ductal stump was histologically positive with non-invasive cancer in three patients and positive with invasive cancer in one. The overall survival of the six patients was 62.5% at 5 years after surgery. CONCLUSIONS While central-HPD was a technically complicated procedure associated with a high morbidity rate, it offered a favorable overall survival and might be an alternative option for DSEBDC patients with a poor hepatic functional reserve.
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Affiliation(s)
- Takashi Mizuno
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan.
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Zhang MZ, Xu XW, Mou YP, Yan JF, Zhu YP, Zhang RC, Zhou YC, Chen K, Jin WW, Matro E, Ajoodhea H. Resection of a cholangiocarcinoma via laparoscopic hepatopancreato- duodenectomy: A case report. World J Gastroenterol 2014; 20:17260-17264. [PMID: 25493044 PMCID: PMC4258600 DOI: 10.3748/wjg.v20.i45.17260] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Revised: 07/31/2014] [Accepted: 09/16/2014] [Indexed: 02/06/2023] Open
Abstract
Some laterally advanced cholangiocarcinomas behave as ductal spread or local invasion, and hepatopancreatoduodenectomy (HPD) may be performed for R0 resection. To date, there have been no reports of laparoscopic HPD (LHPD) in the English literature. We report the first case of LHPD for the resection of a Bismuth IIIa cholangiocarcinoma invading the duodenum. The patient underwent laparoscopic pancreaticoduodenectomy and right hemihepatectomy. Child’s approach was used for the reconstruction. The patient recovered well with bile leakage from the 2nd postoperative day and was discharged on the 16th postoperative day with a drainage tube in place which was removed 2 wk after discharge. Postoperative pathology revealed a well-differentiated cholangiocarcinoma and the margin of liver parenchyma, pancreas and stomach was negative for metastases. The results suggest that LHPD is a feasible and safe procedure when performed in highly specialized centers and in suitable patients with cholangiocarcinoma.
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Ebata T, Yokoyama Y, Igami T, Sugawara G, Mizuno T, Nagino M. Review of hepatopancreatoduodenectomy for biliary cancer: an extended radical approach of Japanese origin. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 21:550-5. [PMID: 24464987 DOI: 10.1002/jhbp.80] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Cholangiocarcinomas exhibit various modes of local extension, and some tumors can only be completely resected by hepatopancreatoduodenectomy (HPD), which is defined as the resection of the whole extrahepatic biliary system with the adjacent liver and pancreatoduodenum. Since Takasaki et al. introduced HPD for locally advanced gallbladder cancer in 1980, Japanese hepatobiliary surgeons have aggressively challenged this extended procedure for advanced biliary tumors. Early experiences with HPD were frequently associated with liver failure and sequential mortality, leading to an underestimation of the survival benefit of HPD. However, with improvements in surgical techniques and perioperative patient care, including portal vein embolization, over the last two decades, the mortality rate after HPD has gradually decreased. Recent studies have demonstrated a favorable survival in cholangiocarcinoma, provided that R0 resection is achieved. In contrast, HPD for gallbladder cancer remains controversial because of the extremely poor survival, although the study populations have been limited. HPD can be performed with low mortality and offers a better probability of long-term survival in patients with cholangiocarcinoma. We should consider HPD to be a standard approach for laterally advanced cholangiocarcinomas that are otherwise unresectable.
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Affiliation(s)
- Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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Liu GJ, Li XH, Chen YX, Sun HD, Zhao GM, Hu SY. Radical lymph node dissection and assessment: Impact on gallbladder cancer prognosis. World J Gastroenterol 2013; 19:5150-5158. [PMID: 23964151 PMCID: PMC3746389 DOI: 10.3748/wjg.v19.i31.5150] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Revised: 05/11/2013] [Accepted: 07/05/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the lymph node metastasis patterns of gallbladder cancer (GBC) and evaluate the optimal categorization of nodal status as a critical prognostic factor.
METHODS: From May 1995 to December 2010, a total of 78 consecutive patients with GBC underwent a radical resection at Liaocheng People’s Hospital. A radical resection was defined as removing both the primary tumor and the regional lymph nodes of the gallbladder. Demographic, operative and pathologic data were recorded. The lymph nodes retrieved were examined histologically for metastases routinely from each node. The positive lymph node count (PLNC) as well as the total lymph node count (TLNC) was recorded for each patient. Then the metastatic to examined lymph nodes ratio (LNR) was calculated. Disease-specific survival (DSS) and predictors of outcome were analyzed.
RESULTS: With a median follow-up time of 26.50 mo (range, 2-132 mo), median DSS was 29.00 ± 3.92 mo (5-year survival rate, 20.51%). Nodal disease was found in 37 patients (47.44%). DSS of node-negative patients was significantly better than that of node-positive patients (median DSS, 40 mo vs 17 mo, χ2 = 14.814, P < 0.001), while there was no significant difference between N1 patients and N2 patients (median DSS, 18 mo vs 13 mo, χ2 = 0.741, P = 0.389). Optimal TLNC was determined to be four. When node-negative patients were divided according to TLNC, there was no difference in DSS between TLNC < 4 subgroup and TLNC ≥ 4 subgroup (median DSS, 37 mo vs 54 mo, χ2 = 0.715, P = 0.398). For node-positive patients, DSS of TLNC < 4 subgroup was worse than that of TLNC ≥ 4 subgroup (median DSS, 13 mo vs 21 mo, χ2 = 11.035, P < 0.001). Moreover, for node-positive patients, a new cut-off value of six nodes was identified for the number of TLNC that clearly stratified them into 2 separate survival groups (< 6 or ≥ 6, respectively; median DSS, 15 mo vs 33 mo, χ2 = 11.820, P < 0.001). DSS progressively worsened with increasing PLNC and LNR, but no definite cut-off value could be identified. Multivariate analysis revealed histological grade, tumor node metastasis staging, TNLC and LNR to be independent predictors of DSS. Neither location of positive lymph nodes nor PNLC were identified as an independent variable by multivariate analysis.
CONCLUSION: Both TLNC and LNR are strong predictors of outcome after curative resection for GBC. The retrieval and examination of at least 6 nodes can influence staging quality and DSS, especially in node-positive patients.
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Is extended hemihepatectomy plus pancreaticoduodenectomy justified for advanced bile duct cancer and gallbladder cancer? Surgery 2013; 153:794-800. [PMID: 23415082 DOI: 10.1016/j.surg.2012.11.024] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 11/28/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Major hepatopancreaticoduodenectomy (HPD) is an extensive surgical procedure offering the highest curability for patients with advanced biliary cancer. However, surgical morbidity associated with major HPD is high, and optimal indications for this procedure remain unclear. METHODS Between 1989 and 2010, 14 patients with widespread bile duct cancer and 5 with gallbladder cancer having biliary infiltration underwent major HPD at our hospital. Preoperative portal vein embolization was performed in 17 patients undergoing right HPD. Clinicopathologic factors and survivals following HPD were compared between patients with bile duct cancer and those with gallbladder cancer. RESULTS One patient who underwent right HPD for gallbladder cancer died of hepatic failure (5.3%) and 18 of the 19 patients (95%) developed postoperative pancreatic fistulas. The median hospital stay was 47 days. Depth of invasion was T3 in 1 patient and T4 in 2 patients with bile duct cancer and was T4 in all 5 patients with gallbladder cancer (P = .002). The clinical stage was IV in 3 patients (21%) with bile duct cancer and in all 5 patients with gallbladder cancer (P = .002). The 5-year survival rates and median survival rates of patients with bile duct cancer and gallbladder cancer were 45% vs 0 and 3.3 years vs 8 months, respectively (P < .001). CONCLUSION HPD can be an acceptable treatment option for widespread bile duct cancer. However, the indication for HPD in advanced-stage gallbladder cancer should be considered carefully, considering the high morbidity rate and the advanced stage of the disease.
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Edwards J, Scoggins C, McMasters K, Martin R. Combined pancreas and liver therapies: Resection and ablation in hepato-pancreatico-biliary malignancies. J Surg Oncol 2013; 107:709-12. [DOI: 10.1002/jso.23318] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Accepted: 12/17/2012] [Indexed: 01/22/2023]
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Nagino M. Perihilar cholangiocarcinoma: a surgeon's viewpoint on current topics. J Gastroenterol 2012; 47:1165-76. [PMID: 22847554 DOI: 10.1007/s00535-012-0628-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 06/09/2012] [Indexed: 02/07/2023]
Abstract
Perihilar cholangiocarcinomas are defined anatomically as "tumors that are located in the extrahepatic biliary tree proximal to the origin of the cystic duct". However, as the boundary between the extrahepatic and intrahepatic bile ducts is not well defined, perihilar cholangiocarcinomas potentially include two types of tumors: one is the "extrahepatic" type, which arises from the large hilar bile duct, and the other is the "intrahepatic" type, which has an intrahepatic component with the invasion of the hepatic hilus. The new TNM staging system published by the International Union Against Cancer (UICC) has been well revised with regard to perihilar cholangiocarcinoma, but it still lacks stratification of patient prognosis and has little applicability for assessing the feasibility of surgical treatment; therefore, further refinement is essential. Most patients with perihilar cholangiocarcinomas present with jaundice, and preoperative biliary drainage is mandatory. Previously, percutaneous transhepatic biliary drainage was used in many centers; however, it is accepted that endoscopic naso-biliary drainage is the most suitable method of preoperative drainage. Portal vein embolization is now widely used as a presurgical treatment for patients undergoing an extended hepatectomy to minimize postoperative liver dysfunction. The surgical resection of a perihilar cholangiocarcinoma is technically demanding and continues to be the most difficult challenge for hepatobiliary surgeons. Because of advances in diagnostic and surgical techniques, surgical outcomes and survival rates after resection have steadily improved. However, survival, especially for patients with lymph node metastasis, is still unsatisfactory, and the establishment of adjuvant chemotherapy is necessary. Further synergy of endoscopists, radiologists, oncologists, and surgeons is required to conquer this intractable disease.
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Affiliation(s)
- Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
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Reappraisal of hepatopancreatoduodenectomy as a treatment modality for bile duct and gallbladder cancer. J Gastrointest Surg 2012; 16:1012-8. [PMID: 22271243 DOI: 10.1007/s11605-012-1826-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Accepted: 01/04/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hepatopancreatoduodenectomy has been performed to achieve radical resection in malignant biliary tumors. We reviewed clinical outcomes to evaluate the clinical feasibility of hepatopancreatoduodenectomy for the treatment of gallbladder and bile duct cancer. METHODS Twenty-three patients underwent hepatopancreatoduodenectomy from 1995 to 2007; 10 gallbladder cancer and 13 bile duct cancer. Median follow-up periods were 15.0 months. RESULTS R0 resection was performed in 17 of 23 patients (73.9%). Morbidity and mortality rates were 91.3% and 13.0%, respectively. Five-year survival rates were 10.0% for gallbladder cancer and 32.3% for bile duct cancer. Survival more than 3 years was possible for most patients with stage IIA or less, whereas all gallbladder cancer patients with stage III and all bile duct cancer with stage IIB or more died within 2 years. Bile duct cancer patients with pN0 survived longer than those with pN1 (p < 0.001). CONCLUSIONS To obtain negative proximal and distal ductal resection margins in the biliary tract cancer, R0 resection and long-term survival can be achieved by hepatopancreatoduodenectomy. However, its adoption in patients with lymph node metastasis or adjacent organ invasion cannot be recommended.
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Survival benefit of hepatopancreatoduodenectomy for cholangiocarcinoma in comparison to hepatectomy or pancreatoduodenectomy. World J Surg 2011; 34:2662-70. [PMID: 20607255 DOI: 10.1007/s00268-010-0702-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Perihilar and distal cholangiocarcinoma remain difficult to treat, and long-term survival is poor. We conducted a retrospective study of patients with cholangiocarcinoma to examine whether hepatopancreatoduodenectomy, in comparison to standard surgeries, provides a survival benefit. METHODS Subjects were 75 patients with perihilar or distal cholangiocarcinoma who, between April 1997 and May 2007, underwent hepatectomy with bile duct resection (Hx, n = 29), pancreatoduodenectomy (PD, n = 32), or hepatopancreatoduodenectomy (HPD, n = 14) at our hospital. We compared surgical outcomes and survival between groups and identified factors negatively influencing survival. RESULTS Morbidity and in-hospital mortality did not differ significantly between groups (Hx group, 34% and 10%, respectively; PD group, 44% and 3%; and HPD, 57% and 0%). The overall median survival time was 39 months, and overall 5-year survival (including in-hospital mortality) was 42%. Respective group values were as follows: Hx, 24 months and 31%; PD, 51 months and 49%, and HPD, 63 months and 50%. Although the number of patients was small, survival in the HPD was not influenced by the type of invasion whether widespread intramural invasion (n = 8), superficial spread (n = 4), or hepatoduodenal ligament invasion (n = 2). Multivariate analysis (Cox proportional hazards model) showed only perineural invasion (p = .007) and decreased curability (R1/2 resection) (p = .017) to be independent risk factors influencing survival. CONCLUSIONS In cases of perihilar or distal cholangiocarcinoma, aggressive surgery must be aimed at overcoming perineural invasion. Our findings indicate that HPD improves survival of patients undergoing surgery for widespread cholangiocarcinoma in comparison to standard surgeries.
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Ruiz-Tovar J, López-Hervas P. Right Hepatectomy Extended to Segment I and Pancreatoduodenectomy in the Same Surgical Act for Pancreatic Neuroendocrine Tumor with Liver Metastases. Am Surg 2010. [DOI: 10.1177/000313481007601242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Hemming AW, Magliocca JF, Fujita S, Kayler LK, Hochwald S, Zendejas I, Kim RD. Combined Resection of the Liver and Pancreas for Malignancy. J Am Coll Surg 2010; 210:808-14, 814-6. [DOI: 10.1016/j.jamcollsurg.2009.12.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2009] [Accepted: 12/08/2009] [Indexed: 12/23/2022]
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Slim K, Blay JY, Brouquet A, Chatelain D, Comy M, Delpero JR, Denet C, Elias D, Fléjou JF, Fourquier P, Fuks D, Glehen O, Karoui M, Kohneh-Shahri N, Lesurtel M, Mariette C, Mauvais F, Nicolet J, Perniceni T, Piessen G, Regimbeau JM, Rouanet P, sauvanet A, Schmitt G, Vons C, Lasser P, Belghiti J, Berdah S, Champault G, Chiche L, Chipponi J, Chollet P, De Baère T, Déchelotte P, Garcier JM, Gayet B, Gouillat C, Kianmanesh R, Laurent C, Meyer C, Millat B, Msika S, Nordlinger B, Paraf F, Partensky C, Peschaud F, Pocard M, Sastre B, Scoazec JY, Scotté M, Triboulet JP, Trillaud H, Valleur P. [Digestive oncology: surgical practices]. ACTA ACUST UNITED AC 2009; 146 Suppl 2:S11-80. [PMID: 19435621 DOI: 10.1016/s0021-7697(09)72398-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- K Slim
- Chirurgien Clermont-Ferrand.
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Nikfarjam M, Sehmbey M, Kimchi ET, Gusani NJ, Shereef S, Avella DM, Staveley-O'Carroll KF. Additional organ resection combined with pancreaticoduodenectomy does not increase postoperative morbidity and mortality. J Gastrointest Surg 2009; 13:915-21. [PMID: 19198960 DOI: 10.1007/s11605-009-0801-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2008] [Accepted: 01/03/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND The mortality associated with pancreaticoduodenectomy (PD) has decreased substantially in recent times, but high morbidity continues to be a significant problem. With reductions in mortality, there is increasing willingness to combine organ resections with PD when indicated. There is, however, a paucity of information regarding the morbidity and mortality of multivisceral resection (MVR) that involves pancreaticoduodenectomy (MVR-PD). METHODS Patients undergoing PD between January 2002 and November 2007 by a single surgeon were reviewed and perioperative outcomes determined. Those treated by PD alone were compared to those undergoing MVR-PD. RESULTS There were 105 patients overall who underwent PD during the study period, with MVR-PD performed in 19 patients. Twelve (63%) patients required PD combined with right colectomy, two (11%) underwent PD combined with right nephrectomy, two (11%) required liver resection with PD, and the remaining three (16%) had various combinations of kidney, colon, adrenal and small bowel resection in addition to PD. In both groups, the main indication for surgery was pancreatic cancer; however, there were proportionally more patients in the MVR-PD group with gastrointestinal stromal tumors (two (11%) patients), sarcomas (two (11%) patients) and metastases to the periampullary region (three (16%) patients). The overall complication rate in this study was 60%. Delayed gastric emptying (39%) and pancreatic fistula (16%) were the most common complications. There was no significant difference in complications between the two groups. A non pylorus-preserving PD was more commonly performed in cases of MVR-PD (53% vs 28%; p = 0.007), operating times were longer (9.5 vs 8 h; p = 0.002), and surgical intensive care unit stay was greater (2 vs 1 days; p < 0.001). The overall median length of hospital stay (7 days) and readmission rate were similar between the groups. CONCLUSION MVR-PD can be performed without significant added morbidity compared to PD alone. The main indication for MVR-PD is locally advanced pancreatic cancer requiring PD combined with right hemicolectomy.
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Affiliation(s)
- Mehrdad Nikfarjam
- Section of Surgical Oncology, Department of Surgery, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, H070, 500 University Drive, P.O. Box 850, Hershey, PA 17033-0850, USA.
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Radical Resection of Biliary Tract Cancers and the Role of Extended Lymphadenectomy. Surg Oncol Clin N Am 2009; 18:339-59, ix. [DOI: 10.1016/j.soc.2008.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Pilgrim CHC, Usatoff V, Evans P. Consideration of anatomical structures relevant to the surgical strategy for managing gallbladder carcinoma. Eur J Surg Oncol 2009; 35:1131-6. [PMID: 19297118 DOI: 10.1016/j.ejso.2009.02.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2008] [Revised: 01/24/2009] [Accepted: 02/02/2009] [Indexed: 12/12/2022] Open
Abstract
AIMS Gallbladder carcinoma usually presents late with advanced disease. It develops in an anatomically complex area. Consideration is given to resection of relevant local structures with respect to outcome. METHODS A comprehensive literature review was performed, searching Medline for articles published since 2000, using the MeSH heading of 'gallbladder cancer' and 'surgery'. Abstracts were reviewed and articles retrieved if the main focus of the article centred on the surgical management of gallbladder carcinoma. OBSERVATIONS Hepatic resection is advocated and tailored to pathological T stage. Lymph node dissection and bile duct resection, as well as en bloc resection of other viscera, remain areas of controversy. CONCLUSIONS Eastern and Western practice standards of care differ, but hepatic resection with some lymph node dissection is present in both approaches. Philosophy regarding aggression with respect to en bloc resection of adjacent organs and actual extent of lymphatic resection remains disparate.
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Affiliation(s)
- Charles H C Pilgrim
- The Alfred Hospital, Upper Gastrointestinal Surgery, Commercial Rd, Melbourne, VIC 3000, Australia.
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Nakamura H, Katayose Y, Rikiyama T, Onogawa T, Yamamoto K, Yoshida H, Hayashi H, Ohtsuka H, Hayashi Y, Egawa SI, Unno M. Advanced bile duct carcinoma in a 15-year-old patient with pancreaticobiliary maljunction and congenital biliary cystic disease. ACTA ACUST UNITED AC 2008; 15:554-9. [DOI: 10.1007/s00534-007-1310-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2007] [Accepted: 09/21/2007] [Indexed: 02/07/2023]
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Combined major hepatectomy and pancreaticoduodenectomy for locally advanced biliary carcinoma: long-term results. World J Surg 2008; 32:1067-74. [PMID: 18231828 DOI: 10.1007/s00268-007-9393-8] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Kim JK, Hwang HK, Park JS, Cho SI, Yoon DS, Chi HS. Left hemihepatectomy and caudate lobectomy and complete extrahepatic bile duct resection using transduodenal approach for hilar cholangiocarcinoma arsing from biliary papillomatosis. J Surg Oncol 2008; 98:139-42. [PMID: 18521837 DOI: 10.1002/jso.21089] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Biliary papillomatosis (BP) is a rare disease characterized by multiple papillary lesions of variable distribution and extent in the intra and extrahepatic bile duct. Hepatopancreatoduodenectomy (HPD) can be indicated for the resection of diffuse intra and extrahepatic BP that extended to the distal bile duct and ampullary region. The mortality rate for HPD has recently decreased but HPD still has a high morbidity rate. In this study, we present a safe procedure for concomitant intrahepatic and extrahepatic BP. PATIENTS AND METHODS Preoperative studies showed showed multiple, variable-sized, and nodular papillary masses with mucin in the left intrahepatic ducts, confluence of the right and left hepatic ducts, common hepatic duct, and whole CBD, but peripheral to the right intrahepatic bile ducts were grossly well preserved. We underwent Lt. hepatectomy and the common bile duct and ampulla of Vater were completely resected with transduodenal approach and the pancreatic duct was repositioned to the duodenal mucosa. CONCLUSIONS Major hepatic resection and transduodenal approach for complete bile duct resection and pancreatic duct repositioning could be an acceptable therapeutic option for concomitant intrahepatic and extrahepatic biliary papillomatosis without the evidence of pancreatic duct involvement in the patients with severe comorbidity.
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Affiliation(s)
- Jae Keun Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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Nimura Y. Radical surgery: vascular and pancreatic resection for cholangiocarcinoma. HPB (Oxford) 2008; 10:183-5. [PMID: 18773051 PMCID: PMC2504372 DOI: 10.1080/13651820801992682] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2008] [Indexed: 12/12/2022]
Abstract
Recent progress in vascular surgical techniques has made it possible to combine liver and portal vein and/or hepatic artery (HA) or retrohepatic inferior vena cava (IVC) resection and reconstruction in cases of locally advanced cholangiocarcinoma. Reports of the success of this difficult surgery have been published. Aggressive Japanese surgeons have applied hepatopancreatoduodenectomy (HPD) not just in cases of advanced gallbladder cancer, but also in locally advanced cholangiocarcinoma with or without superficial spread. The above extended surgeries were associated with high postoperative morbidity and mortality, but recent progress in perioperative management and surgical techniques has improved the outcome of these types of surgery. Combined portal vein and liver resection provides R0 resection and contributes to longer survival in resected patients with locally advanced cholangiocarcinoma than in unresected patients. Portal vein invasion is a strong prognostic factor of cholangiocarcinoma and the actual number of 5-year survivors is limited. The number of clinical cases of liver resection combined with IVC or HA resection and reconstruction is still limited, and therefore the long-term survival benefit from these procedures has not been clarified. HPD carried high morbidity and mortality rates in the 1990s, but the outcome has been improving and an increasing number of 5-year survivors has been reported. Although the clinical value of the above extended surgeries has not been evaluated prospectively, with the increasing number of retrospective studies it has been concluded that combined liver and portal vein and/or HA or IVC resection or HPD could be indicated for selected patients with locally advanced cholangiocarcinoma.
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