|
1
|
Ahmad Al-Saffar H, Jansson H, Danielsson O, Moro CF, Sturesson C. Different biliary tract cancers, same operation: Importance of cancer origin in patients with hilar-invading tumors. Scand J Surg 2025; 114:35-43. [PMID: 39380179 DOI: 10.1177/14574969241282480] [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] [Indexed: 10/10/2024]
Abstract
BACKGROUND AND AIMS For patients with biliary tract cancer involving the hepatic hilum, major hepatic resection with extrahepatic bile duct resection may be required. In addition to perihilar cholangiocarcinoma (PHCC), the same extent of surgery is used in advanced gallbladder cancer (GBC) and intrahepatic cholangiocarcinoma (IHCC) with hilar involvement. Few studies compare prognostic factors and long-term outcomes across tumor types. This study compared risk characteristics and outcomes after surgery in all subtypes of biliary tract cancer with hilar involvement. METHODS Patients with biliary tract cancer with hilar involvement undergoing major liver resection and extrahepatic bile duct resection between 2011 and 2021 at a single center were retrospectively analyzed. The primary postoperative outcome was overall survival. Secondary outcomes were recurrence-free survival and postoperative complications. Survival analysis was performed with Cox regression analysis and Kaplan-Meier method. RESULTS One-hundred and eight patients were included. Seventy-three (67%) had PHCC, 24 (22%) had GBC, and 11 (10%) had IHCC. Hilar-invading IHCC and GBC had more adverse histopathological factors like lymph node positivity (p = 0.021), higher number of positive nodes (p = 0.043), and larger tumor size (p < 0.001) compared with PHCC. Peritoneal invasion and lymph node positivity were significant independent predictors for survival (p = 0.011 and p = 0.004, respectively). Median overall survival was 29 months for PHCC, 22 months for GBC and 21 months for IHCC (p = 0.53). IHCC tended to recur earlier (p = 0.046) than GBC and PHCC (6, 15, and 18 months, respectively). CONCLUSION Patients with biliary tract cancer with hilar involvement undergoing major liver resection and resection of extrahepatic bile ducts had similar overall survival regardless of subtype, while IHCC recurred earlier. Peritoneal cancer invasion was common in all subtypes, including PHCC, and was an independent prognostic factor. This finding may support routine reporting of peritoneal invasion-status in resected biliary tract cancer.
Collapse
Affiliation(s)
- Hasan Ahmad Al-Saffar
- Division of Surgery Department of Clinical Science, Intervention and Technology (CLINTEC) Karolinska University Hospital, Karolinska Institutet, Alfred Nobels alle 8, Huddinge 141 52, Sverige
| | - Hannes Jansson
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Olof Danielsson
- Department of Clinical Pathology and Cytology, Karolinska University Hospital, Stockholm, Sweden
- Division of Pathology, Department of Laboratory Medicine (LABMED), Karolinska Institutet, Stockholm, Sweden
| | - Carlos F Moro
- Department of Clinical Pathology and Cytology, Karolinska University Hospital, Stockholm, Sweden
- Division of Pathology, Department of Laboratory Medicine (LABMED), Karolinska Institutet, Stockholm, Sweden
| | - Christian Sturesson
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
|
2
|
Malik AK, Davidson BR, Manas DM. Surgical management, including the role of transplantation, for intrahepatic and peri-hilar cholangiocarcinoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2025; 51:108248. [PMID: 38467524 DOI: 10.1016/j.ejso.2024.108248] [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: 02/26/2024] [Revised: 02/28/2024] [Accepted: 03/03/2024] [Indexed: 03/13/2024]
Abstract
Intrahepatic and peri-hilar cholangiocarcinoma are life threatening disease with poor outcomes despite optimal treatment currently available (5-year overall survival following resection 20-35%, and <10% cured at 10-years post resection). The insidious onset makes diagnosis difficult, the majority do not have a resection option and the high recurrence rate post-resection suggests that occult metastatic disease is frequently present. Advances in perioperative management, such as ipsilateral portal vein (and hepatic vein) embolisation methods to increase the future liver remnant volume, genomic profiling, and (neo)adjuvant therapies demonstrate great potential in improving outcomes. However multiple areas of controversy exist. Surgical resection rate and outcomes vary between centres with no global consensus on how 'resectable' disease is defined - molecular profiling and genomic analysis could potentially identify patients unlikely to benefit from resection or likely to benefit from targeted therapies. FDG-PET scanning has also improved the ability to detect metastatic disease preoperatively and avoid futile resection. However tumours frequently invade major vasculo-biliary structures, with resection and reconstruction associated with significant morbidity and mortality even in specialist centres. Liver transplantation has been investigated for very selected patients for the last decade and yet the selection algorithm, surgical approach and both value of both neoadjuvant and adjuvant therapies remain to be clarified. In this review, we discuss the contemporary management of intrahepatic and peri-hilar cholangiocarcinoma.
Collapse
Affiliation(s)
- Abdullah K Malik
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle Upon Tyne, UK.
| | - Brian R Davidson
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK; Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Derek M Manas
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle Upon Tyne, UK; NHS Blood and Transplant, Bristol, UK
| |
Collapse
|
|
3
|
Vaghiri S, Prassas D, Kalmuk S, Buehler G, Lehwald-Tywuschik N, Knoefel WT, Dizdar L, Alexander A. Comparative study of short-and long-term results in patients with perihilar cholangiocarcinoma undergoing surgical resection: does the extent and side of resection really affect outcome? Minerva Surg 2024; 79:419-429. [PMID: 38953755 DOI: 10.23736/s2724-5691.24.10326-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
BACKGROUND The surgical management of perihilar carcinoma (pCCA) is still subject of ongoing debate. To provide more clarity, this study was conducted to evaluate outcomes related to the side and extent of heatectomy in patients with pCAA. METHODS A total of 32 patients with curative resection for pCCA were identified from our prospective database. Short-and long-term clinical outcome data and histopathological results were compared between right-sided (R-H) and left-sided (L-H) hepatectomy. RESULTS Nine patients (28.13%) underwent left-sided hepatectomy while a right-sided hepatectomy was accomplished in 23 patients (71.87%). In the R-H group hepatic conditioning of the future liver remnant (FLR) prior to extended resection was necessary in 13 cases (56.52%), and simultaneous pancreaticoduodenectomy was performed in 5 patients (21.74%). The arterial and portal venous reconstruction rates were 17.39% and 11.11% (P=1.00), and 60.87% and 33.33% (P=0.243) in the R-H and L-H groups, respectively. No statistically significant differences in short-term morbidity and mortality between both groups were observed. The rate of R0 resections was comparable (R-H: 78.26% versus L-H: 66.67%; P=0.654) resulting in similar long-term overall and disease-free survival rates after right-and left hepatectomy. CONCLUSIONS In patients with pCCA, both right- and left-sided resections appear to be safe and feasible options with similar postoperative morbidity and oncologic outcomes. Consecutively, the ideal surgical approach should be patient-tailored based on anatomical considerations and the functional future liver capacity.
Collapse
Affiliation(s)
- Sascha Vaghiri
- Department of Surgery, University Hospital of Duesseldorf, Heinrich Heine University Düsseldorf, Duesseldorf, Germany
| | - Dimitrios Prassas
- Department of Surgery, University Hospital of Duesseldorf, Heinrich Heine University Düsseldorf, Duesseldorf, Germany
- Department of Surgery, Katholisches Klinikum Essen, Philippusstift, Teaching Hospital of Duisburg-Essen University, Essen, Germany
| | - Sinan Kalmuk
- Department of Surgery, University Hospital of Duesseldorf, Heinrich Heine University Düsseldorf, Duesseldorf, Germany
| | - Geoffrey Buehler
- Department of Surgery, University Hospital of Duesseldorf, Heinrich Heine University Düsseldorf, Duesseldorf, Germany
| | - Nadja Lehwald-Tywuschik
- Department of Surgery, University Hospital of Duesseldorf, Heinrich Heine University Düsseldorf, Duesseldorf, Germany
| | - Wolfram T. Knoefel
- Department of Surgery, University Hospital of Duesseldorf, Heinrich Heine University Düsseldorf, Duesseldorf, Germany -
| | - Levent Dizdar
- Department of Surgery, University Hospital of Duesseldorf, Heinrich Heine University Düsseldorf, Duesseldorf, Germany
| | - Andrea Alexander
- Department of Surgery, University Hospital of Duesseldorf, Heinrich Heine University Düsseldorf, Duesseldorf, Germany
| |
Collapse
|
|
4
|
Hu XS, Wang Y, Pan HT, Zhu C, Chen SL, Zhou S, Liu HC, Pang Q, Jin H. "Hepatic hilum area priority, liver posterior first": An optimized strategy in laparoscopic resection for type III-IV hilar cholangiocarcinoma. World J Gastrointest Surg 2024; 16:2167-2174. [PMID: 39087123 PMCID: PMC11287698 DOI: 10.4240/wjgs.v16.i7.2167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/31/2024] [Accepted: 06/20/2024] [Indexed: 07/22/2024] Open
Abstract
BACKGROUND In recent years, pure laparoscopic radical surgery for Bismuth-Corlette type III and IV hilar cholangiocarcinoma (HCCA) has been preliminarily explored and applied, but the surgical strategy and safety are still worthy of further improvement and attention. AIM To summarize and share the application experience of the emerging strategy of "hepatic hilum area dissection priority, liver posterior separation first" in pure laparoscopic radical resection for patients with HCCA of Bismuth-Corlette types III and IV. METHODS The clinical data and surgical videos of 6 patients with HCCA of Bismuth-Corlette types III and IV who underwent pure laparoscopic radical resection in our department from December 2021 to December 2023 were retrospectively analyzed. RESULTS Among the 6 patients, 4 were males and 2 were females. The average age was 62.2 ± 11.0 years, and the median body mass index was 20.7 (19.2-24.1) kg/m2. The preoperative median total bilirubin was 57.7 (16.0-155.7) μmol/L. One patient had Bismuth-Corlette type IIIa, 4 patients had Bismuth-Corlette type IIIb, and 1 patient had Bismuth-Corlette type IV. All patients successfully underwent pure laparoscopic radical resection following the strategy of "hepatic hilum area dissection priority, liver posterior separation first". The operation time was 358.3 ± 85.0 minutes, and the intraoperative blood loss volume was 195.0 ± 108.4 mL. None of the patients received blood transfusions during the perioperative period. The median length of stay was 8.3 (7.0-10.0) days. Mild bile leakage occurred in 2 patients, and all patients were discharged without serious surgery-related complications. CONCLUSION The emerging strategy of "hepatic hilum area dissection priority, liver posterior separation first" is safe and feasible in pure laparoscopic radical surgery for patients with HCCA of Bismuth-Corlette types III and IV. This strategy is helpful for promoting the modularization and process of pure laparoscopic radical surgery for complicated HCCA, shortens the learning curve, and is worthy of further clinical application.
Collapse
Affiliation(s)
- Xiao-Si Hu
- Department of Hepatopancreatobiliary Surgery, Anhui No. 2 Provincial People's Hospital, Hefei 230041, Anhui Province, China
| | - Yong Wang
- Department of Hepatopancreatobiliary Surgery, Anhui No. 2 Provincial People's Hospital, Hefei 230041, Anhui Province, China
| | - Hong-Tao Pan
- Department of Hepatopancreatobiliary Surgery, Anhui No. 2 Provincial People's Hospital, Hefei 230041, Anhui Province, China
| | - Chao Zhu
- Department of Hepatopancreatobiliary Surgery, Anhui No. 2 Provincial People's Hospital, Hefei 230041, Anhui Province, China
| | - Shi-Lei Chen
- Department of Hepatopancreatobiliary Surgery, Anhui No. 2 Provincial People's Hospital, Hefei 230041, Anhui Province, China
| | - Shuai Zhou
- Department of Hepatopancreatobiliary Surgery, Anhui No. 2 Provincial People's Hospital, Hefei 230041, Anhui Province, China
| | - Hui-Chun Liu
- Department of Hepatopancreatobiliary Surgery, Anhui No. 2 Provincial People's Hospital, Hefei 230041, Anhui Province, China
| | - Qing Pang
- Department of Hepatopancreatobiliary Surgery, Anhui No. 2 Provincial People's Hospital, Hefei 230041, Anhui Province, China
| | - Hao Jin
- Department of Hepatopancreatobiliary Surgery, Anhui No. 2 Provincial People's Hospital, Hefei 230041, Anhui Province, China
| |
Collapse
|
|
5
|
Esmail A, Badheeb M, Alnahar B, Almiqlash B, Sakr Y, Khasawneh B, Al-Najjar E, Al-Rawi H, Abudayyeh A, Rayyan Y, Abdelrahim M. Cholangiocarcinoma: The Current Status of Surgical Options including Liver Transplantation. Cancers (Basel) 2024; 16:1946. [PMID: 38893067 PMCID: PMC11171350 DOI: 10.3390/cancers16111946] [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: 04/09/2024] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 06/21/2024] Open
Abstract
Cholangiocarcinoma (CCA) poses a substantial threat as it ranks as the second most prevalent primary liver tumor. The documented annual rise in intrahepatic CCA (iCCA) incidence in the United States is concerning, indicating its growing impact. Moreover, the five-year survival rate after tumor resection is only 25%, given that tumor recurrence is the leading cause of death in 53-79% of patients. Pre-operative assessments for iCCA focus on pinpointing tumor location, biliary tract involvement, vascular encasements, and metastasis detection. Numerous studies have revealed that portal vein embolization (PVE) is linked to enhanced survival rates, improved liver synthetic functions, and decreased overall mortality. The challenge in achieving clear resection margins contributes to the notable recurrence rate of iCCA, affecting approximately two-thirds of cases within one year, and results in a median survival of less than 12 months for recurrent cases. Nearly 50% of patients initially considered eligible for surgical resection in iCCA cases are ultimately deemed ineligible during surgical exploration. Therefore, staging laparoscopy has been proposed to reduce unnecessary laparotomy. Eligibility for orthotopic liver transplantation (OLT) requires certain criteria to be granted. OLT offers survival advantages for early-detected unresectable iCCA; it can be combined with other treatments, such as radiofrequency ablation and transarterial chemoembolization, in specific cases. We aim to comprehensively describe the surgical strategies available for treating CCA, including the preoperative measures and interventions, alongside the current options regarding liver resection and OLT.
Collapse
Affiliation(s)
- Abdullah Esmail
- Section of GI Oncology, Department of Medicine, Houston Methodist Cancer Center, Houston, TX 77030, USA
| | - Mohamed Badheeb
- Department of Internal Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT 06605, USA
| | - Batool Alnahar
- College of Medicine, Almaarefa University, Riyadh 13713, Saudi Arabia
| | - Bushray Almiqlash
- Zuckerman College of Public Health, Arizona State University, Tempe, AZ 85287, USA
| | - Yara Sakr
- Department of GI Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Bayan Khasawneh
- Section of GI Oncology, Department of Medicine, Houston Methodist Cancer Center, Houston, TX 77030, USA
| | - Ebtesam Al-Najjar
- Section of GI Oncology, Department of Medicine, Houston Methodist Cancer Center, Houston, TX 77030, USA
| | - Hadeel Al-Rawi
- Faculty of Medicine, The University of Jordan, Amman 11942, Jordan
| | - Ala Abudayyeh
- Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Yaser Rayyan
- Department of Gastroenterology & Hepatology, Faculty of Medicine, The University of Jordan, Amman 11942, Jordan
| | - Maen Abdelrahim
- Section of GI Oncology, Department of Medicine, Houston Methodist Cancer Center, Houston, TX 77030, USA
| |
Collapse
|
|
6
|
Otto CC, Mantas A, Heij LR, Heise D, Dewulf M, Lang SA, Ulmer TF, Dahl E, Bruners P, Neumann UP, Bednarsch J. Preoperative predictors for non-resectability in perihilar cholangiocarcinoma. World J Surg Oncol 2024; 22:48. [PMID: 38326854 PMCID: PMC10851609 DOI: 10.1186/s12957-024-03329-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 01/30/2024] [Indexed: 02/09/2024] Open
Abstract
INTRODUCTION Explorative laparotomy without subsequent curative-intent liver resection remains a major clinical problem in the treatment of perihilar cholangiocarcinoma (pCCA). Thus, we aimed to identify preoperative risk factors for non-resectability of pCCA patients. MATERIAL AND METHODS Patients undergoing surgical exploration between 2010 and 2022 were eligible for the analysis. Separate binary logistic regressions analyses were used to determine risk factors for non-resectability after explorative laparotomy due to technical (tumor extent, vessel infiltration) and oncological (peritoneal carcinomatosis, distant nodal or liver metastases)/liver function reasons. RESULTS This monocentric cohort comprised 318 patients with 209 (65.7%) being surgically resected and 109 (34.3%) being surgically explored [explorative laparotomy: 87 (27.4%), laparoscopic exploration: 22 (6.9%)]. The median age in the cohort was 69 years (range 60-75) and a majority had significant comorbidities with ASA-Score ≥ 3 (202/318, 63.5%). Statistically significant (p < 0.05) risk factors for non-resectability were age above 70 years (HR = 3.76, p = 0.003), portal vein embolization (PVE, HR = 5.73, p = 0.007), and arterial infiltration > 180° (HR = 8.05 p < 0.001) for technical non-resectability and PVE (HR = 4.67, p = 0.018), arterial infiltration > 180° (HR = 3.24, p = 0.015), and elevated CA 19-9 (HR = 3.2, p = 0.009) for oncological/liver-functional non-resectability. CONCLUSION Advanced age, PVE, arterial infiltration, and elevated CA19-9 are major risk factors for non-resectability in pCCA. Preoperative assessment of those factors is crucial for better therapeutical pathways. Diagnostic laparoscopy, especially in high-risk situations, should be used to reduce the amount of explorative laparotomies without subsequent liver resection.
Collapse
Affiliation(s)
- Carlos Constantin Otto
- Department of Surgery and Transplantation, University Hospital Essen, Essen, Germany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Anna Mantas
- Department of Surgery and Transplantation, University Hospital Essen, Essen, Germany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Lara Rosaline Heij
- Department of Surgery and Transplantation, University Hospital Essen, Essen, Germany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Daniel Heise
- Department of Surgery and Transplantation, University Hospital Essen, Essen, Germany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Maxime Dewulf
- Department of Surgery, Maastricht University Medical Center (MUMC), Maastricht, Netherlands
| | - Sven Arke Lang
- Department of Surgery and Transplantation, University Hospital Essen, Essen, Germany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Tom Florian Ulmer
- Department of Surgery and Transplantation, University Hospital Essen, Essen, Germany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Edgar Dahl
- Institute of Pathology, University Hospital RWTH Aachen, Aachen, Germany
| | - Philipp Bruners
- Department of Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Ulf Peter Neumann
- Department of Surgery and Transplantation, University Hospital Essen, Essen, Germany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Department of Surgery, Maastricht University Medical Center (MUMC), Maastricht, Netherlands
| | - Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital Essen, Essen, Germany.
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany.
| |
Collapse
|
|
7
|
Polyakov AN, Patyutko YI, Kotelnikov AG, Frantsev DY, Korshak AV, Uzbekova AA, Egenov OA, Pokataev IA, Savchenko IV, Podluzhny DV. [Surgical treatment and prognostic factors in perihilar tumors]. Khirurgiia (Mosk) 2024:14-23. [PMID: 38344956 DOI: 10.17116/hirurgia202402114] [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] [Indexed: 02/15/2024]
Abstract
OBJECTIVE To study the results of surgical treatment in patients with perihilar tumors. MATERIAL AND METHODS We analyzed 98 patients with perihilar tumors who underwent surgery. RESULTS We prefer percutaneous transhepatic biliary drainage (n=58) for jaundice. Retrograde interventions were performed in 18 cases (20.5%), complications grade III-IV were more common (p=0.037) in the last group. Postoperative mortality was 12%. Complications developed in 81 patients (82.7%), grade ≥3 - in 39 (39.8%) cases. Portal vein resection (n=26) increased the incidence of complications grade ≥III (p=0.035) and portal vein thrombosis (p=0.0001). Chemotherapy after surgery was performed in 47 patients (48.0%), photodynamic therapy - in 7 (7.1%) patients. A 5-year overall survival was 28.1%, the median survival - 29 months. R2 resection and/or M1 stage (n=12) significantly worsened the prognosis and overall survival (16.5 vs. 31 months, p=0.0055). Lymph node (LN) lesion, microscopic status (R0 vs. R1) of resection margin, technique of decompression and isolated resection of extrahepatic bile ducts did not affect the prognosis, and we combined appropriate patients (n=72) for analysis. SI resection and excision of ≥6 lymph nodes were independent positive factors for disease-free survival (p=0.042 and p=0.007, respectively). Blood transfusion and high preoperative neutrophil-lymphocyte index (NLI ≥2.15) worsened overall (p=0.009 and p=0.002, respectively) and disease-free survival (p=0.002 and 0.007, respectively). The absence of adjuvant therapy worsened disease-free survival alone (p=0.024). CONCLUSION SI liver resection, adequate lymph node dissection and adjuvant therapy should be used for perihilar tumors. Isolated resection of extrahepatic bile ducts is permissible in some cases. Blood transfusion and NLI ≥2.15 are independent negative prognostic factors.
Collapse
Affiliation(s)
- A N Polyakov
- Blokhin National Medical Cancer Research Center, Moscow, Russia
| | - Yu I Patyutko
- Blokhin National Medical Cancer Research Center, Moscow, Russia
| | - A G Kotelnikov
- Blokhin National Medical Cancer Research Center, Moscow, Russia
| | - D Yu Frantsev
- Blokhin National Medical Cancer Research Center, Moscow, Russia
| | - A V Korshak
- Blokhin National Medical Cancer Research Center, Moscow, Russia
| | - A A Uzbekova
- Blokhin National Medical Cancer Research Center, Moscow, Russia
| | - O A Egenov
- Blokhin National Medical Cancer Research Center, Moscow, Russia
| | - I A Pokataev
- Moscow City Clinical Oncology Hospital No.1, Moscow, Russia
| | - I V Savchenko
- Blokhin National Medical Cancer Research Center, Moscow, Russia
| | - D V Podluzhny
- Blokhin National Medical Cancer Research Center, Moscow, Russia
| |
Collapse
|
|
8
|
Lemaire M, Vibert É, Azoulay D, Salloum C, Ciacio O, Pittau G, Allard MA, Sa Cunha A, Adam R, Cherqui D, Golse N. Early portal vein thrombosis after hepatectomy for perihilar cholangiocarcinoma: Incidence, risk factors, and management. J Visc Surg 2023; 160:417-426. [PMID: 37407290 DOI: 10.1016/j.jviscsurg.2023.06.005] [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] [Indexed: 07/07/2023]
Abstract
AIM To study the incidence, risk factors and management of portal vein thrombosis (PVT) after hepatectomy for perihilar cholangiocarcinoma (PHCC). PATIENTS AND METHOD Single-center retrospective analysis of 86 consecutive patients who underwent major hepatectomy for PHCC, between 2012 and 2019, with comparison of the characteristics of the groups with (PVT+) and without (PVT-) postoperative portal vein thrombosis. RESULTS Seven patients (8%) presented with PVT diagnosed during the first postoperative week. Preoperative portal embolization had been performed in 71% of patients in the PVT+ group versus 34% in the PVT- group (P=0.1). Portal reconstruction was performed in 100% and 38% of PVT+ and PVT- patients, respectively (P=0.002). In view of the gravity of the clinical and/or biochemical picture, five (71%) patients underwent urgent re-operation with portal thrombectomy, one of whom died early (hemorrhagic shock after surgical treatment of PVT). Two patients had exclusively medical treatment. Complete recanalization of the portal vein was achieved in the short and medium term in the six survivors. After a mean follow-up of 21 months, there was no statistically significant difference in overall survival between the two groups. FINDINGS Post-hepatectomy PVT for PHCC is a not-infrequent and potentially lethal event. Rapid management, adapted to the extension of the thrombus and the severity of the thrombosis (hepatic function, signs of portal hypertension) makes it possible to limit the impact on postoperative mortality. We did not identify any modifiable risk factor. However, when it is oncologically and anatomically feasible, left±extended hepatectomy (without portal embolization) may be less risky than extended right hepatectomy, and portal vein resection should only be performed if there is strong suspicion of tumor invasion.
Collapse
Affiliation(s)
- Mégane Lemaire
- Hepato-Biliary Center, Paul-Brousse Hospital, Assistance publique-Hôpitaux de Paris, 94800 Villejuif, France
| | - Éric Vibert
- Hepato-Biliary Center, Paul-Brousse Hospital, Assistance publique-Hôpitaux de Paris, 94800 Villejuif, France; UMRS 1193, Paris-Saclay University, Inserm, Pathogenesis and treatment of liver diseases, FHU Hepatinov, 94800 Villejuif, France
| | - Daniel Azoulay
- Hepato-Biliary Center, Paul-Brousse Hospital, Assistance publique-Hôpitaux de Paris, 94800 Villejuif, France
| | - Chady Salloum
- Hepato-Biliary Center, Paul-Brousse Hospital, Assistance publique-Hôpitaux de Paris, 94800 Villejuif, France
| | - Oriana Ciacio
- Hepato-Biliary Center, Paul-Brousse Hospital, Assistance publique-Hôpitaux de Paris, 94800 Villejuif, France
| | - Gabriella Pittau
- Hepato-Biliary Center, Paul-Brousse Hospital, Assistance publique-Hôpitaux de Paris, 94800 Villejuif, France
| | - Marc-Antoine Allard
- Hepato-Biliary Center, Paul-Brousse Hospital, Assistance publique-Hôpitaux de Paris, 94800 Villejuif, France
| | - Antonio Sa Cunha
- Hepato-Biliary Center, Paul-Brousse Hospital, Assistance publique-Hôpitaux de Paris, 94800 Villejuif, France; UMRS 1193, Paris-Saclay University, Inserm, Pathogenesis and treatment of liver diseases, FHU Hepatinov, 94800 Villejuif, France
| | - René Adam
- Hepato-Biliary Center, Paul-Brousse Hospital, Assistance publique-Hôpitaux de Paris, 94800 Villejuif, France; "Chronotherapy, Cancers and Transplantation" Research Team, Paris-Saclay University, France INSERM, Paris, France
| | - Daniel Cherqui
- Hepato-Biliary Center, Paul-Brousse Hospital, Assistance publique-Hôpitaux de Paris, 94800 Villejuif, France; UMRS 1193, Paris-Saclay University, Inserm, Pathogenesis and treatment of liver diseases, FHU Hepatinov, 94800 Villejuif, France
| | - Nicolas Golse
- Hepato-Biliary Center, Paul-Brousse Hospital, Assistance publique-Hôpitaux de Paris, 94800 Villejuif, France; UMRS 1193, Paris-Saclay University, Inserm, Pathogenesis and treatment of liver diseases, FHU Hepatinov, 94800 Villejuif, France.
| |
Collapse
|
|
9
|
Dondorf F, Graf M, Deeb AA, Rohland O, Felgendreff P, Ardelt M, Settmacher U, Rauchfuss F. Pathogen detection in patients with perihilar cholangiocarcinoma: Implications for targeted perioperative antibiotic therapy. Hepatobiliary Pancreat Dis Int 2023; 22:512-518. [PMID: 35153139 DOI: 10.1016/j.hbpd.2022.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 12/10/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Cholestasis should be relieved by biliary drainage prior to major liver resection. This condition is often associated with bacterial colonization of the otherwise sterile biliary system. Cholangitis reduces the regenerative capacity of the remaining liver. Therefore, targeted antibiotic therapy is a key feature in perioperative treatment in patients with perihilar cholangiocarcinoma (pCCC). METHODS Between December 1999 and December 2017, 251 pCCC patients were treated in our center. In total, 115 patients underwent a microbiological analysis. In addition to the characterization of the specific microorganisms and antibiotic resistance, we analyzed subgroups according to preoperative intervention. RESULTS Enterococci (87/254, 34%) and Enterobacteria (65/254, 26%) were the most frequently detected genera. In 43% (50/115) of patients, Enterococcus faecalis was found in the bile duct sample. Enterococcus faecium (29/115) and Escherichia coli (29/115) were detected in 25% of patients. In patients with percutaneous transhepatic biliary drainage (3/8, 38%) or stents (24/79, 30%), Enterococcus faecium was diagnosed most frequently (P < 0.05). Enterococcus faecium and Klebsiella oxytoca were significantly more frequently noted in the time period after 2012 (P < 0.05). With regard to fungal colonization, the focus was on various Candida strains, but these strains generally lacked resistance. CONCLUSIONS pCCC patients exhibit specific bacterial colonization features depending on the type of preoperative biliary intervention. Specifically, targeted antibiosis should be applied in this patient cohort to minimize the risk of biliary complications after major liver resection. In our cohort, the combination of meropenem and vancomycin represents an effective perioperative medical approach.
Collapse
Affiliation(s)
- Felix Dondorf
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Jena 07747, Germany.
| | - Maximilian Graf
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Jena 07747, Germany
| | - Aladdin Ali Deeb
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Jena 07747, Germany
| | - Oliver Rohland
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Jena 07747, Germany
| | - Philipp Felgendreff
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Jena 07747, Germany; Research Program "Else Kröner-Forschungskolleg AntiAge", Jena University Hospital, Jena 07747, Germany
| | - Michael Ardelt
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Jena 07747, Germany
| | - Utz Settmacher
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Jena 07747, Germany
| | - Falk Rauchfuss
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Jena 07747, Germany
| |
Collapse
|
|
10
|
Liu X, Hu Z, Zhou X, Qin J, Xing Z, Liang Y, Liu J, Xu H, Su L, Li A, Liu J. Application of a New Approach for Laparoscopic Resection of Bismuth IIIa Hilar Cholangiocarcinoma. J Laparoendosc Adv Surg Tech A 2023; 33:969-974. [PMID: 37603304 DOI: 10.1089/lap.2023.0085] [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] [Indexed: 08/22/2023] Open
Abstract
Background: Hilar cholangiocarcinoma (HCCA) has a high degree of malignancy and poor prognosis, and the best long-term prognosis can only be achieved by radical resection. However, the surgical steps are complicated, and the operating space is limited, making it hard to complete laparoscopically. So our team proposes a new surgical approach for laparoscopic left-liver-first anterior radical modular orthotopic right hemihepatectomy (Lap-Larmorh). In this way, we can simplify the operation steps and reduce the difficulty. Materials and Methods: We recorded and analyzed the clinical data of 26 patients with type IIIa HCCA, who underwent laparoscopic radical resection in our department from December 2018 to January 2023. According to the laparoscopic surgical approach, we divided the patients into the new approach (NA) group (n = 14) using the Lap-Lamorh and the traditional approach (TA) group (n = 12) not using the Lap-Lamorh. Results: All surgeries in this study were completed laparoscopically with no conversion to open surgery. The operation time in the NA group and TA group had statistically significant differences, which was 372.5 (332.8, 420.0) minutes versus 423.5 (385.8, 498.8) minutes (P = .019). The two groups showed no significant difference in other characteristics (P > .05). Only 1 patient suffered from transient liver failure due to portal vein thrombosis. Patients with pleural effusion or ascites were cured by catheter drainage and enhanced nutrition. Conclusion: Lap-Larmorh reduces the difficulty of serving the vessels at the second and third hepatic hilum by splitting the right and left livers early intraoperatively. The new approach is more suitable for the narrow space of laparoscopic surgery and reflects the no-touch principle of oncology.
Collapse
Affiliation(s)
- Xueqing Liu
- Department of Hepatobiliary Surgery, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zixuan Hu
- Department of Hepatobiliary Surgery, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xinbo Zhou
- Department of Hepatobiliary Surgery, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jianzhang Qin
- Department of Hepatobiliary Surgery, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhongqiang Xing
- Department of Hepatobiliary Surgery, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yunfei Liang
- Department of Hepatobiliary Surgery, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jia Liu
- Department of Radiology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Haihe Xu
- Department of General Surgery, Dagang Hospital, Binhai New Area, Tianjin, China
| | - Lingling Su
- Department of General Surgery, Lincheng County People's Hospital, Xingtai, China
| | - Ang Li
- Hepatobiliary Surgery Department, First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jianhua Liu
- Department of Hepatobiliary Surgery, Second Hospital of Hebei Medical University, Shijiazhuang, China
| |
Collapse
|
|
11
|
Jena SS, Mehta NN, Nundy S. Surgical management of hilar cholangiocarcinoma: Controversies and recommendations. Ann Hepatobiliary Pancreat Surg 2023; 27:227-240. [PMID: 37408334 PMCID: PMC10472117 DOI: 10.14701/ahbps.23-028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 07/07/2023] Open
Abstract
Hilar cholangiocarcinomas are highly aggressive malignancies. They are usually at an advanced stage at initial presentation. Surgical resection with negative margins is the standard of management. It provides the only chance of cure. Liver transplantation has increased the number of 'curative' procedures for cases previously considered to be unresectable. Meticulous and thorough preoperative planning is required to prevent fatal post-operative complications. Extended resection procedures, including hepatic trisectionectomy for Bismuth type IV tumors, hepatopancreaticoduodenectomy for tumors with extensive longitudinal spread, and combined vascular resection with reconstruction for tumors involving hepatic vascular structures, are challenging procedures with surgical indications expanded. Liver transplantation after the standardization of a neoadjuvant protocol described by the Mayo Clinic has increased the number of patients who can undergo operation.
Collapse
Affiliation(s)
- Suvendu Sekhar Jena
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| | - Naimish N Mehta
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| | - Samiran Nundy
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
| |
Collapse
|
|
12
|
Makino K, Ishii T, Yoh T, Ogiso S, Fukumitsu K, Seo S, Taura K, Hatano E. The usefulness of preoperative bile cultures for hepatectomy with biliary reconstruction. Heliyon 2022; 8:e12226. [PMID: 36568677 PMCID: PMC9768314 DOI: 10.1016/j.heliyon.2022.e12226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 05/23/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022] Open
Abstract
Background Infectious complications can cause lethal liver failure after hepatectomy with biliary reconstruction. This study assessed the increased risk for postoperative infectious complications in patients who underwent hepatectomy with biliary reconstruction and explored the possibility of predicting pathogenic microorganisms causing postoperative infectious complications based on preoperative monitoring of bile cultures. Methods This study involved 310 patients who received major hepatectomy with or without biliary reconstruction at our institution between January 2010 and December 2019. The relationship between the microorganisms detected through perioperative monitoring of bile culture and those in the postoperative infectious foci was examined. Results Forty-nine patients underwent major hepatectomy with biliary reconstruction, and 261 received hepatectomy without biliary reconstruction. The multivariate analysis revealed hepatectomy with biliary reconstruction to be associated with an increased risk of postoperative infectious complications (odds ratio: 22.9, 95% confidence interval: 5.2-164.3) compared to hepatectomy without biliary reconstruction. In the patients with biliary reconstruction, the concordance rates between the microorganisms detected in the postoperative infectious foci and those in preoperative bile cultures were as follows: incisional surgical site infection (44.4%), organ/space surgical site infection (52.9%), bacteremia (47.1%), and pneumonia (16.7%); the concordance rates were high, and the risk of infection increased over time. Conclusions Biliary reconstruction is a significant risk factor for postoperative infectious complications, and preoperative bile cultures may aid in prophylactic and therapeutic antimicrobial agent selection.
Collapse
|
|
13
|
Zhang X, Cai Y, Xiong X, Liu A, Zhou R, You Z, Li F, Cheng N. Comparison of current guidelines and consensus on the management of patients with cholangiocarcinoma: 2022 update. Intractable Rare Dis Res 2022; 11:161-172. [PMID: 36457589 PMCID: PMC9709616 DOI: 10.5582/irdr.2022.01109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 11/06/2022] [Accepted: 11/23/2022] [Indexed: 11/28/2022] Open
Abstract
As a consequence of breakthroughs in the area of guidelines research, the therapy for cholangiocarcinoma has significantly improved the efficacy rate of diagnosis and survival outcomes. We compared the most recently updated clinical practice guidelines and consensus to provide recommendations based on the diagnostic and therapeutic equipment available in various countries. Following a systematic review, we discovered that these guidelines and consensus had both similarities and differences in terms of what organizations or groups drafted the guidelines and the approach, applicability, content and recent updates of the guidelines as well as in terms of diagnostic and treatment algorithms. The disparities could be attributable to a variety of etiological factors, high risk patients, health resources, medical technology, treatment options, and income levels. Additionally, while complete adoption of guidelines may benefit physicians, patients, and authorities, there remains a disconnect between expected goals and implementation.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Nansheng Cheng
- Address correspondence to:Nansheng Cheng, Division of Biliary Surgery, Department of General Surgery, West China Hospital, Sichuan University, No.37 Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China. E-mail:
| |
Collapse
|
|
14
|
Schmelzle M, Benzing C, Fischer L, Herden U, Sterneck M, Settmacher U, Bauschke A, Neumann U, Pelzer U, Müller T, Strassburg C, Lang H, Becker T, Königsrainer A, Nadalin S, Quante M, Paul A, Friess H, Klempnauer J, Richter N, Vondran F, Pascher A, Rösch T, Schöning W, Krenzien F, Öllinger R, Seehofer D, Neuhaus P, Pratschke J. Feasibility and Efficacy of Adjuvant Chemotherapy With Gemcitabine After Liver Transplantation for Perihilar Cholangiocarcinoma - A Multi-Center, Randomized, Controlled Trial (pro-duct001). Front Oncol 2022; 12:910871. [PMID: 36330499 PMCID: PMC9624225 DOI: 10.3389/fonc.2022.910871] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/19/2022] [Indexed: 11/14/2022] Open
Abstract
Background Liver transplantation (LT) is considered a therapeutic option for unresectable perihilar cholangiocarcinoma (PHC) within defined criteria. It remains uncertain whether patients can safely receive adjuvant chemotherapy after LT. Methods We performed a prospective, multi-center, randomized, non-blinded two-arm trial (pro-duct001). Patients after LT for unresectable PHC within defined criteria were randomized to adjuvant gemcitabine (LT-Gem group) and LT alone (LT alone group). The primary objective was to investigate if adjuvant chemotherapy is feasible in ≥ 85% of patients after LT. The primary endpoint was the percentage of patients completing the 24 weeks course of adjuvant chemotherapy. Secondary endpoints included overall survival (OS) and disease-free (DFS), and complication rates. Results Twelve patients underwent LT for PHC, of which six (50%) were eligible for randomization (LT-Gem: three patients, LT alone: three patients). Two out of three patients discontinued adjuvant chemotherapy after LT due to intolerance. The study was prematurely terminated due to slow enrollment. One patient with PHC had underlying primary sclerosing cholangitis (PSC). Tumor-free margins could be achieved in all patients. In both the LT-Gem and the LT alone group, the cumulative 1-, 3-, and 5-year OS and DFS rates were 100%, 100%, 67%, and 100%, 67% and 67%, respectively. Conclusions This prospective, multi-center study was prematurely terminated due to slow enrollment and a statement on the defined endpoints cannot be made. Nevertheless, long-term survival data are consistent with available retrospective data and confirm defined criteria for LT. Since more evidence of LT per se in unresectable PHC is urgently needed, a prospective, non-randomized follow-up study (pro-duct002) has since been launched.
Collapse
Affiliation(s)
- Moritz Schmelzle
- Department of Surgery, Charité – Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of General, Visceral and Transplant Surgery, Medizinische Hochschule Hannover, Hannover, Germany
| | - Christian Benzing
- Department of Surgery, Charité – Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Lutz Fischer
- Department of Visceral Transplant Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Herden
- Department of Visceral Transplant Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Martina Sterneck
- Department of Medicine I, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Utz Settmacher
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Jena, Germany
| | - Astrid Bauschke
- Department of General, Visceral and Vascular Surgery, University Hospital Jena, Jena, Germany
| | - Ulf Neumann
- Department of General, Visceral and Transplant Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Uwe Pelzer
- Department of Medicine - Hematology, Oncology and Tumour Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Tobias Müller
- Department of Medicine - Hepatology and Gastroenterology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Hauke Lang
- Department of General, Visceral and Transplant Surgery, University Hospital Mainz, Mainz, Germany
| | - Thomas Becker
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Alfred Königsrainer
- Department of General, Visceral and Transplant, University Hospital Tübingen, Tübingen, Germany
| | - Silvio Nadalin
- Department of General, Visceral and Transplant, University Hospital Tübingen, Tübingen, Germany
| | - Markus Quante
- Department of General, Visceral and Transplant, University Hospital Tübingen, Tübingen, Germany
| | - Andreas Paul
- Department of General, Visceral and Transplant, University Hospital Essen, Essen, Germany
| | - Helmut Friess
- Department of General, Visceral, Thoracic and Transplant, University Hospital rechts der Isar, München, Germany
| | - Jürgen Klempnauer
- Department of General, Visceral and Transplant Surgery, Medizinische Hochschule Hannover, Hannover, Germany
| | - Nicolas Richter
- Department of General, Visceral and Transplant, University Hospital Tübingen, Tübingen, Germany
| | - Florian Vondran
- Department of General, Visceral and Transplant, University Hospital Tübingen, Tübingen, Germany
| | - Andreas Pascher
- Department of General, Visceral and Transplant, University Hospital Münster, Münster, Germany
| | - Thomas Rösch
- University Hospital Hamburg-Eppendorf, Klinik und Poliklinik für Interdisziplinäre Endoskopie, Hamburg, Germany
| | - Wenzel Schöning
- Department of Surgery, Charité – Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Felix Krenzien
- Department of Surgery, Charité – Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Robert Öllinger
- Department of Surgery, Charité – Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Daniel Seehofer
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Peter Neuhaus
- Department of Surgery, Charité – Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Charité – Universitätsmedizin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- *Correspondence: Johann Pratschke,
| |
Collapse
|
|
15
|
Lurje I, Czigany Z, Eischet S, Bednarsch J, Ulmer TF, Isfort P, Strnad P, Trautwein C, Tacke F, Neumann UP, Lurje G. The prognostic impact of preoperative body composition in perihilar and intrahepatic cholangiocarcinoma. Hepatol Commun 2022; 6:2400-2417. [PMID: 35616275 PMCID: PMC9426393 DOI: 10.1002/hep4.2004] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/31/2022] [Accepted: 04/22/2022] [Indexed: 11/25/2022] Open
Abstract
Cholangiocarcinoma (CCA) is a rare but highly aggressive malignancy of the biliary system. Although it is amenable to surgical resection in early disease, outcomes are frequently dismal. Here, we investigated the prevalence of body composition (BC) alterations and their prognostic role for surgical patients with intrahepatic (iCCA) and perihilar (pCCA) disease. Patients undergoing curative‐intent surgery for iCCA or pCCA between 2010 and 2019 at University Hospital Aachen were included. Axial computed tomography images were retrospectively assessed with a segmentation tool (3D Slicer) at the level of the third lumbar vertebra to determine lumbar skeletal muscle (SM) index, mean SM radiation attenuation, and visceral fat area. The related BC pathologies sarcopenia, myosteatosis, visceral obesity, and sarcopenic obesity were determined using previously described cutoffs. A total of 189 patients (86 with iCCA, 103 with pCCA) were included. Alterations of BC were highly prevalent in iCCA and pCCA, respectively: sarcopenia, 33% (28/86) and 39% (40/103); myosteatosis, 66% (57/86) and 66% (68/103); visceral obesity, 56% (48/86) and 67% (69/103); sarcopenic obesity, 11% (9/86) and 17% (17/103). Sarcopenia and myosteatosis did not have a significant prognostic role for disease‐free survival (DFS) and overall survival (OS). Patients with iCCA with sarcopenic obesity (n = 9) had significantly shorter OS than patients without sarcopenic obesity (n = 7; log‐rank p = 0.002; median OS, 11 months and 31 months; 1‐year mortality, 55.6% [5/9] and 22% [17/77]; 5‐year mortality, 88.9% [8/9] and 61% [47/77], respectively). In multivariable analysis, only tumor‐related risk factors remained prognostic for DFS and OS. Sarcopenic obesity may affect clinical outcomes after curative‐intent surgery for iCCA, indicating that imaging‐based analysis of BC may hold prognostic value for long‐term survival and could aid preoperative patient selection.
Collapse
Affiliation(s)
- Isabella Lurje
- Department of Hepatology and Gastroenterology, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Sarah Eischet
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Tom Florian Ulmer
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Peter Isfort
- Institute of Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Pavel Strnad
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Christian Trautwein
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Ulf Peter Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany.,Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Georg Lurje
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| |
Collapse
|
|
16
|
Preoperative Osteopenia Is Associated with Significantly Shorter Survival in Patients with Perihilar Cholangiocarcinoma. Cancers (Basel) 2022; 14:cancers14092213. [PMID: 35565342 PMCID: PMC9103099 DOI: 10.3390/cancers14092213] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/06/2022] [Accepted: 04/26/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Osteopenia is defined as low bone mineral density (BMD) and has been shown to be associated with outcomes of patients with various cancers. The association between osteopenia and perihilar cholangiocarcinoma is unknown. The aim of this study was to evaluate osteopenia as a prognostic factor in patients with perihilar cholangiocarcinoma. Methods: A total of 58 patients who underwent surgery for perihilar cholangiocarcinoma were retrospectively analyzed. The BMD at the 11th thoracic vertebra was measured using computed tomography scan within one month of surgery. Patients with a BMD < 160 HU were considered to have osteopenia and b BMD ≥ 160 did not have osteopenia. The log-rank test was performed for survival using the Kaplan−Meier method. After adjusting for confounding factors, overall survival was assessed by Cox′s proportional-hazards model. Results: The osteopenia group had 27 (47%) more females than the non-osteopenia group (p = 0.036). Median survival in the osteopenia group was 37 months and in the non-osteopenia group was 61 months (p = 0.034). In multivariable analysis, osteopenia was a significant independent risk factor associated with overall survival in patients with perihilar cholangiocarcinoma (hazard ratio 3.54, 95% confidence interval 1.09−11.54, p = 0.036), along with primary tumor stage. Conclusions: Osteopenia is associated with significantly shorter survival in patients with perihilar cholangiocarcinoma.
Collapse
|
|
17
|
Hosokawa I, Furukawa K, Takayashiki T, Kuboki S, Takano S, Miyazaki M, Ohtsuka M. Surgical implications of the confluence patterns of the left intrahepatic bile ducts in right hepatectomy for perihilar cholangiocarcinoma. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:460-468. [PMID: 34498387 DOI: 10.1002/jhbp.1044] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Although the most important goal in surgery for perihilar cholangiocarcinoma (PHC) is to achieve tumor-free proximal ductal margins, little is known about the implications of confluence patterns of the left intrahepatic bile ducts for the proximal ductal margin status in right hepatectomy (RH) for PHC. METHODS Of 203 patients who underwent surgical resection for PHC with curative intent, confluence patterns of the left intrahepatic bile duct were evaluated in 94 consecutive patients who underwent RH, and they were classified into the following two types: normal type: the bile duct of segment 4 (B4) drained into the common trunk of the bile ducts of segment 2 (B2) and segment 3 (B3) at the right side of the umbilical portion of the left portal vein to form the left hepatic duct; and hepatic confluence type: B2 entered the common trunk of B3 and B4 at the hepatic confluence or B4 entered the common trunk of B2 and B3 at the hepatic confluence. The proximal ductal margin status following RH was compared between the two types of confluence patterns. RESULTS Of 94 consecutive patients, 69 (73%) were the normal type, and 25 (27%) were the hepatic confluence type. There were no significant differences in patients' characteristics, surgical characteristics, surgical outcomes, and histopathological features between the two groups. However, in patients with Bismuth-Corlette type II and IIIa PHC, the achievement rates of negative proximal ductal margins at the first dividing line were significantly higher in the hepatic confluence type group than in the normal type group (16/16 [100%] vs 34/52 [65%], respectively; P = .007). CONCLUSIONS Confluence patterns of the left intrahepatic bile ducts might affect proximal ductal margin status in RH for PHC.
Collapse
Affiliation(s)
- Isamu Hosokawa
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Katsunori Furukawa
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Tsukasa Takayashiki
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Satoshi Kuboki
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shigetsugu Takano
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masaru Miyazaki
- Narita Hospital, International University of Health and Welfare, Chiba, Japan
| | - Masayuki Ohtsuka
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| |
Collapse
|
|
18
|
Benzing C, Haiden LM, Krenzien F, Mieg A, Wolfsberger A, Atik CF, Nevermann N, Fehrenbach U, Schöning W, Schmelzle M, Pratschke J. Textbook outcome after major hepatectomy for perihilar cholangiocarcinoma - definitions and influencing factors. Langenbecks Arch Surg 2022; 407:1561-1573. [PMID: 35246771 PMCID: PMC9283152 DOI: 10.1007/s00423-022-02467-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/09/2022] [Indexed: 11/28/2022]
Abstract
Purpose The concept of “textbook outcome” (TO) as composite quality measure depicting the ideal surgical has not yet been defined for patients undergoing major hepatectomy (MH) for perihilar cholangiocarcinoma (PHC). This study sought to propose a uniform definition through a systematic literature review as well as to identify patient- or procedure-related factors influencing TO. Methods In this retrospective study, we analyzed all patients undergoing MH for PHC at our department between January 2005 and August 2019. After conducting a systematic literature search, we defined TO as the absence of 90-day mortality and major complications, no hospital readmission within 90 days after discharge, and no prolonged hospital stay (<75. percentile). A binary logistic regression analysis was performed to identify factors influencing TO. Results Of 283 patients, TO was achieved in 67 (24%) patients. Multivariate analysis revealed that preoperative biliary drainage was associated with a decreased (OR= 0.405, 95% CI: 0.194–0.845, p=0.016) and left-sided-resection (OR= 1.899, 95% CI: 1.048–3.440, p=0.035) with increased odds for TO. Overall survival (OS) and DFS (disease-free survival) did not differ significantly between the outcome groups (OS: p=0.280, DFS: p=0.735). However, there was a trend towards better overall survival, especially in the late course with TO. Conclusion Our analysis proposed a uniform definition of TO after MH for PHC. We identified left hepatectomy as an independent factor positively influencing TO. In patients where both right- and left-sided resections are feasible, this underlines the importance of a careful selection of patients who are scheduled for right hepatectomy. Supplementary Information The online version contains supplementary material available at 10.1007/s00423-022-02467-y.
Collapse
Affiliation(s)
- Christian Benzing
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Lena Marie Haiden
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Felix Krenzien
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Alexa Mieg
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Annika Wolfsberger
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Cecilia Filiz Atik
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Nora Nevermann
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Uli Fehrenbach
- Department of Radiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Wenzel Schöning
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Moritz Schmelzle
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum, Experimental Surgery and Regenerative Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| |
Collapse
|
|
19
|
Perihilar cholangiocarcinoma: What the radiologist needs to know. Diagn Interv Imaging 2022; 103:288-301. [DOI: 10.1016/j.diii.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 03/02/2022] [Indexed: 11/17/2022]
|
|
20
|
Franken LC, Benzing C, Krenzien F, Schmelzle M, van Dieren S, Olthof PB, van Gulik TM, Pratschke J. Right-sided resection with standard or selective portal vein resection in patients with perihilar cholangiocarcinoma: a propensity score analysis. HPB (Oxford) 2022; 24:391-397. [PMID: 34330643 DOI: 10.1016/j.hpb.2021.06.429] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 04/27/2021] [Accepted: 06/21/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Standard portal vein resection (PVR) has been proposed to improve oncological outcomes in patients with perihilar cholangiocarcinoma (PHC), however it potentially introduces an increased risk of morbidity. The policy in Amsterdam UMC(AMC) is to resect the portal vein bifurcation selectively when involved, while in Charité-Universitätsmedizin Berlin, standard PVR is performed with right trisectionectomy. The objective of this study was to analyze postoperative outcomes and survival after standard or selective PVR for PHC. METHODS A retrospective study was performed including PHC-patients undergoing right-sided resection in Amsterdam (2000-2018) and Berlin (2005-2015). Primary outcomes were 90-day mortality, severe morbidity (Clavien-Dindo≥3), and overall survival (OS). A propensity score comparison (1:1 ratio) was performed corrected for age/sex/ASA/jaundice/tumor diameter/N-stage/Bismuth-Corlette type-IV. RESULTS A total of 251 patients who underwent right-sided resection for PHC were evaluated: 87 in the selective (Amsterdam) and 164 in the standard PVR-group (Berlin). Major differences in baseline characteristics were observed, with higher ASA and AJCC-stage in the standard PVR-group (Berlin). Severe morbidity and 90-day mortality were comparable before matching (selective/Amsterdam:68% and 19%, standard/Berlin:61% and 17%,p = 0.284 and p = 0.746, respectively). After propensity score matching, both short term outcomes and OS were comparable (selective/Amsterdam (n = 45) 33 months (95%CI:20-45), standard/Berlin (n = 45) 31 months (95%CI:24-38,p = 0.747)). CONCLUSION In this combined cohort, standard PVR was not associated with increased severe morbidity or mortality. After propensity score matching, survival was comparable after selective (Amsterdam) and standard PVR (Berlin).
Collapse
Affiliation(s)
- Lotte C Franken
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Christian Benzing
- Department of Surgery, Charité-Universitätsmedizin Berlin, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany.
| | - Felix Krenzien
- Department of Surgery, Charité-Universitätsmedizin Berlin, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - Moritz Schmelzle
- Department of Surgery, Charité-Universitätsmedizin Berlin, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| | - Susan van Dieren
- Epidemiologist, Department of Surgery, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Pim B Olthof
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands; Department of Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Johann Pratschke
- Department of Surgery, Charité-Universitätsmedizin Berlin, Campus Charité Mitte, Campus Virchow-Klinikum, Berlin, Germany
| |
Collapse
|
|
21
|
Fukuda J, Tanaka K, Matsui A, Nakanishi Y, Asano T, Noji T, Nakamura T, Tsuchikawa T, Okamura K, Hirano S. Bacteremia after hepatectomy and biliary reconstruction for biliary cancer: the characteristics of bacteremia according to occurrence time and associated complications. Surg Today 2022; 52:1373-1381. [PMID: 35107650 DOI: 10.1007/s00595-022-02462-2] [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: 10/05/2021] [Accepted: 12/27/2021] [Indexed: 12/07/2022]
Abstract
PURPOSE Bacteremia occurring after extensive hepatic resection and biliary reconstruction (Hx + Bx) for biliary cancer is a critical infectious complication. This study evaluated postoperative bacteremia and examined the potential usefulness of surveillance cultures. METHODS We retrospectively reviewed 179 patients who underwent Hx + Bx for biliary cancer from January 2008 to December 2018 in our department. RESULTS Bacteremia occurred in 41 (23.0%) patients. Patients with bacteremia had a longer operation time and more frequent intraoperative transfusion and more frequently developed organ/space surgical site infection (SSI) than those without bacteremia. The most frequently isolated bacterial species from blood cultures were Enterococcus faecium (29.3%), Enterobacter cloacae (24.4%), and Enterococcus faecalis (22.0%). The SIRS duration of bacteremia associated with organ/space SSI was significantly longer than that of other infectious complications (median 96 h vs. 48 h; p = 0.043). Bacteremia associated with organ/space SSI occurred most often by postoperative day (POD) 30. The concordance rate of bacterial species between blood and surveillance cultures within POD 30 was 67-82%. CONCLUSIONS Bacteremia associated with organ/space SSI required treatment for a long time and typically occurred by POD 30. Postoperative surveillance cultures obtained during this period may be useful for selecting initial antibiotic therapy because of their high concordance rate with blood cultures.
Collapse
Affiliation(s)
- Junki Fukuda
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, North 15, West 7, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Kimitaka Tanaka
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, North 15, West 7, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan.
| | - Aya Matsui
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, North 15, West 7, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Yoshitsugu Nakanishi
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, North 15, West 7, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Toshimichi Asano
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, North 15, West 7, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Takehiro Noji
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, North 15, West 7, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Toru Nakamura
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, North 15, West 7, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Takahiro Tsuchikawa
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, North 15, West 7, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Keisuke Okamura
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, North 15, West 7, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, North 15, West 7, Kita-ku, Sapporo, Hokkaido, 060-8648, Japan
| |
Collapse
|
|
22
|
Benzing C, Schmelzle M, Atik CF, Krenzien F, Mieg A, Haiden LM, Wolfsberger A, Schöning W, Fehrenbach U, Pratschke J. Factors associated with failure to rescue after major hepatectomy for perihilar cholangiocarcinoma: A 15-year single-center experience. Surgery 2022; 171:859-866. [DOI: 10.1016/j.surg.2021.08.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 12/20/2022]
|
|
23
|
Kar I, Qayum K, Sofi J. Indications and Complications of Hepatic Resection Patients at Sher-I-Kashmir Institute of Medical Sciences: An Observational Study. Cureus 2021; 13:e19713. [PMID: 34934577 PMCID: PMC8684362 DOI: 10.7759/cureus.19713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2021] [Indexed: 11/05/2022] Open
Abstract
Aim: This study aimed to determine the indications and demographic profile of hepatic resection at Sher-I-Kashmir Institute of Medical Sciences (SKIMS), the performed types of hepatic resection, as well as assess the details of the operation and perioperative complications of hepatic resection. Methods: This is a prospective, retrospective observational study. The retrospective study period was from January 2005 to August 2015 and the prospective study period was from 2015 till 2017. Prospective patients were clinically evaluated by medical history and clinical examination and also underwent various investigations. The patients were scored on Child-Pugh and American Society of Anesthesiology (ASA) scores for risk stratification and prepared for surgery, which included segmentectomy to major liver resection. The retrospective data were obtained from the Medical Records Department (MRD). Statistical analysis was done on SPSS software 25.0 version (Armonk, NY: IBM Corp.). Results: This study included 122 patients with a male to female ratio of 1:1.59. The patients' age was between 1 and 73 years. The patients' most common complaint was right upper quadrant abdominal pain. The main established clinical diagnosis was oriental cholangiohepatitis (OCH) (36.9%) followed by carcinoma of gallbladder (CaGB) which accounted for 37 cases (30.4%). Liver metastases including solitary masses and multiple lesions were 10 cases (8.2%). Fifty-five patients underwent left lateral segmentectomy (45.1%) and mostly for OCH. Standard wedge resection was done in 30.7% of cases and for all cases of CaGB. The mean blood loss was 146.5 ml. A total of 37 patients had complications. Wound infection was the most common complication, occurring in 10 patients (8.2%). Conclusion: Patients with hepatobiliary pathology, necessitating liver resection are now routinely admitted to the Department of Surgical Gastroenterology in SKIMS, Srinagar. Patients are carefully evaluated and operated with a confirmed definitive diagnosis. The overall surgical outcome does not differ from India's best centers.
Collapse
|
|
24
|
Mueller M, Breuer E, Mizuno T, Bartsch F, Ratti F, Benzing C, Ammar-Khodja N, Sugiura T, Takayashiki T, Hessheimer A, Kim HS, Ruzzenente A, Ahn KS, Wong T, Bednarsch J, D'Silva M, Koerkamp BG, Jeddou H, López-López V, de Ponthaud C, Yonkus JA, Ismail W, Nooijen LE, Hidalgo-Salinas C, Kontis E, Wagner KC, Gunasekaran G, Higuchi R, Gleisner A, Shwaartz C, Sapisochin G, Schulick RD, Yamamoto M, Noji T, Hirano S, Schwartz M, Oldhafer KJ, Prachalias A, Fusai GK, Erdmann JI, Line PD, Smoot RL, Soubrane O, Robles-Campos R, Boudjema K, Polak WG, Han HS, Neumann UP, Lo CM, Kang KJ, Guglielmi A, Park JS, Fondevila C, Ohtsuka M, Uesaka K, Adam R, Pratschke J, Aldrighetti L, De Oliveira ML, Gores GJ, Lang H, Nagino M, Clavien PA. Perihilar Cholangiocarcinoma - Novel Benchmark Values for Surgical and Oncological Outcomes From 24 Expert Centers. Ann Surg 2021; 274:780-788. [PMID: 34334638 DOI: 10.1097/sla.0000000000005103] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to define robust benchmark values for the surgical treatment of perihilar cholangiocarcinomas (PHC) to enable unbiased comparisons. BACKGROUND Despite ongoing efforts, postoperative mortality and morbidity remains high after complex liver surgery for PHC. Benchmark data of best achievable results in surgical PHC treatment are however still lacking. METHODS This study analyzed consecutive patients undergoing major liver surgery for PHC in 24 high-volume centers in 3 continents over the recent 5-year period (2014-2018) with a minimum follow-up of 1 year in each patient. Benchmark patients were those operated at high-volume centers (≥50 cases during the study period) without the need for vascular reconstruction due to tumor invasion, or the presence of significant co-morbidities such as severe obesity (body mass index ≥35), diabetes, or cardiovascular diseases. Benchmark cutoff values were derived from the 75th or 25th percentile of the median values of all benchmark centers. RESULTS Seven hundred eight (39%) of a total of 1829 consecutive patients qualified as benchmark cases. Benchmark cut-offs included: R0 resection ≥57%, postoperative liver failure (International Study Group of Liver Surgery): ≤35%; in-hospital and 3-month mortality rates ≤8% and ≤13%, respectively; 3-month grade 3 complications and the CCI: ≤70% and ≤30.5, respectively; bile leak-rate: ≤47% and 5-year overall survival of ≥39.7%. Centers operating mostly on complex cases disclosed better outcome including lower post-operative liver failure rates (4% vs 13%; P = 0.002). Centers from Asia disclosed better outcomes. CONCLUSION Surgery for PHC remains associated with high morbidity and mortality with now the availability of benchmark values covering 21 outcome parameters, which may serve as key references for comparison in any future analyses of individuals, group of patients or centers.
Collapse
Affiliation(s)
- Matteo Mueller
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland
| | - Eva Breuer
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland
| | - Takashi Mizuno
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Fabian Bartsch
- Department of General, Visceral and Transplantation Surgery, University Medical Center, Mainz, Germany
| | - Francesca Ratti
- Division of Hepatobiliary Surgery, IRCCS San Raffaele Hospital, Vita - Salute University, Milan, Italy
| | | | | | - Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Tsukasa Takayashiki
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Amelia Hessheimer
- General and Digestive Surgery Department, Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Hyung Sun Kim
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Andrea Ruzzenente
- Unit of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Keun Soo Ahn
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, School of Medicine, Keimyung University, Dongsan Hospital, Daegu, Republic of Korea
| | - Tiffany Wong
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Jan Bednarsch
- Department of General, Gastrointestinal, Hepatobiliary and Transplant Surgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Mizelle D'Silva
- Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Bas Groot Koerkamp
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Heithem Jeddou
- Service de Chirurgie Hépatobiliaire et Digestive, CHU Rennes, Univ Rennes, Rennes, France
| | - Victor López-López
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, Murcia, Spain
| | - Charles de Ponthaud
- Department of HPB And Pancreatic surgery, Beaujon University Hospital, Clichy, France
| | - Jennifer A Yonkus
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN
| | - Warsan Ismail
- Department of Hepatobiliary and Pancreatic Surgery, Oslo University Hospital, Oslo, Norway
| | - Lynn E Nooijen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Camila Hidalgo-Salinas
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, London, United Kingdom
| | - Elissaios Kontis
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Kim C Wagner
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Asklepios Hospital Barmbek, Semmelweis University Budapest, Faculty of Medicine, Asklepios Campus Hamburg, Hamburg, Germany
| | - Ganesh Gunasekaran
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Ana Gleisner
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Chaya Shwaartz
- Multi-Organ Transplant and HPB Surgical Oncology, Division of General Surgery, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Gonzalo Sapisochin
- Multi-Organ Transplant and HPB Surgical Oncology, Division of General Surgery, University Health Network, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Richard D Schulick
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Takehiro Noji
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Myron Schwartz
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Karl J Oldhafer
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Asklepios Hospital Barmbek, Semmelweis University Budapest, Faculty of Medicine, Asklepios Campus Hamburg, Hamburg, Germany
| | - Andreas Prachalias
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Giuseppe K Fusai
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, London, United Kingdom
| | - Joris I Erdmann
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Pål-Dag Line
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Rory L Smoot
- Division of Hepatobiliary and Pancreatic Surgery, Mayo Clinic, Rochester, MN
| | - Olivier Soubrane
- Department of HPB And Pancreatic surgery, Beaujon University Hospital, Clichy, France
| | - Ricardo Robles-Campos
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, Murcia, Spain
| | - Karim Boudjema
- Service de Chirurgie Hépatobiliaire et Digestive, CHU Rennes, Univ Rennes, Rennes, France
| | - Wojciech G Polak
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Ho-Seong Han
- Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ulf P Neumann
- Department of General, Gastrointestinal, Hepatobiliary and Transplant Surgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Chung-Mau Lo
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Koo Jeong Kang
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, School of Medicine, Keimyung University, Dongsan Hospital, Daegu, Republic of Korea
| | - Alfredo Guglielmi
- Unit of General and Hepatobiliary Surgery, Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
| | - Joon Seong Park
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Constantino Fondevila
- General and Digestive Surgery Department, Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Masayuki Ohtsuka
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - René Adam
- The Centre Hépato-Biliaire, Hôpital Paul Brousse, Villejuif, France
| | - Johann Pratschke
- Department of Surgery, Charité-Universitätsmedizin, Berlin, Germany
| | - Luca Aldrighetti
- Division of Hepatobiliary Surgery, IRCCS San Raffaele Hospital, Vita - Salute University, Milan, Italy
| | - Michelle L De Oliveira
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland
| | - Gregory J Gores
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | - Hauke Lang
- Department of General, Visceral and Transplantation Surgery, University Medical Center, Mainz, Germany
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland
| |
Collapse
|
|
25
|
Clinical and oncological benefits of left hepatectomy for Bismuth type I/II perihilar cholangiocarcinoma. Surg Today 2021; 52:844-852. [PMID: 34724106 DOI: 10.1007/s00595-021-02401-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 08/27/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE This retrospective study aimed to clarify whether the postoperative prognosis differs between right and left hepatectomy for Bismuth type I/II perihilar cholangiocarcinoma. METHODS Preoperative images of 195 patients with perihilar cholangiocarcinoma were reexamined. Patients with Bismuth type I/II perihilar cholangiocarcinoma without a difference in extraductal tumor invasion between the right and left sides of the hepatic portal region were classified into those undergoing left (L group) or right (R group) hepatectomy. RESULTS Twenty-three patients (11.8%) were classified into the L group and 33 (16.9%) into the R group. All eight patients with pTis/1 belonged to the L group. The L group had significantly less liver failure than the R group (p = 0.001). One patient (4.3%) in the L group and four patients (12.1%) in the R group died from postoperative complications. Among 48 patients with pT2, the L group tended to have better overall survival (median, 12.2 vs. 5.6 years; p = 0.072), but not recurrence-free survival (median, 9.1 vs. 3.6 years; p = 0.477), in comparison to the R group. CONCLUSIONS Postoperative survival after left hepatectomy for Bismuth type I/II perihilar cholangiocarcinoma is expected to be as long as that after right hepatectomy.
Collapse
|
|
26
|
Nagino M, Clavien PA. Demise of "Hilar En Bloc Resection by No-touch Technique" as Surgery for Perihilar Cholangiocarcinoma: Dissociation Between Theory and Practice. Ann Surg 2021; 274:e385-e387. [PMID: 34117151 DOI: 10.1097/sla.0000000000004986] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Masato Nagino
- Department of Gastroenterological Surgery, Aichi Cancer Center, Nagoya, Japan
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
|
27
|
Radulova-Mauersberger O, Weitz J, Riediger C. Vascular surgery in liver resection. Langenbecks Arch Surg 2021; 406:2217-2248. [PMID: 34519878 PMCID: PMC8578135 DOI: 10.1007/s00423-021-02310-w] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 08/18/2021] [Indexed: 01/04/2023]
Abstract
Vascular surgery in liver resection is a standard part of liver transplantation, but is also used in oncological liver surgery. Malignant liver tumors with vascular involvement have a poor prognosis without resection. Surgery is currently the only treatment to provide long-term survival in advanced hepatic malignancy. Even though extended liver resections are increasingly performed, vascular involvement with need of vascular reconstruction is still considered a contraindication for surgery in many institutions. However, vascular resection and reconstruction in liver surgery-despite being complex procedures-are safely performed in specialized centers. The improvements of the postoperative results with reduced postoperative morbidity and mortality are a result of rising surgical and anesthesiological experience and advancements in multimodal treatment concepts with preconditioning measures regarding liver function and systemic treatment options. This review focuses on vascular surgery in oncological liver resections. Even though many surgical techniques were developed and are also used during liver transplantation, this special procedure is not particularly covered within this review article. We provide a summary of vascular reconstruction techniques in oncological liver surgery according to the literature and present also our own experience. We aim to outline the current advances and standards in extended surgical procedures for liver tumors with vascular involvement established in specialized centers, since curative resection improves long-term survival and shifts palliative concepts to curative therapy.
Collapse
Affiliation(s)
- Olga Radulova-Mauersberger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany.
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.
- German Cancer Research Center (DKFZ), Heidelberg, Germany.
- Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
- Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Carina Riediger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| |
Collapse
|
|
28
|
Serrablo A, Serrablo L, Alikhanov R, Tejedor L. Vascular Resection in Perihilar Cholangiocarcinoma. Cancers (Basel) 2021; 13:5278. [PMID: 34771439 PMCID: PMC8582407 DOI: 10.3390/cancers13215278] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/14/2021] [Accepted: 10/18/2021] [Indexed: 12/16/2022] Open
Abstract
Among the cholangiocarcinomas, the most common type is perihilar (phCC), accounting for approximately 60% of cases, after which are the distal and then intrahepatic forms. There is no staging system that allows for a comparison of all series and extraction of conclusions that increase the long-term survival rate of this dismal disease. The extension of the resection, which theoretically depends on the type of phCC, is not a closed subject. As surgery is the only known way to achieve a cure, many aggressive approaches have been adopted. Despite extended liver resections and even vascular resections, margins are positive in around one third of patients. In the past two decades, with advances in diagnostic and surgical techniques, surgical outcomes and survival rates have gradually improved, although variability is the rule, with morbidity and mortality rates ranging from 14% to 76% and from 0% to 19%, respectively. Extended hepatectomies and portal vein resection, or even right hepatic artery reconstruction for the left side tumors are frequently needed. Salvage procedures when arterial reconstruction is not feasible, as well as hepatopancreatoduodenectomy, are still under evaluation too. In this article, we discuss the aggressive surgical approach to phCC focused on vascular resection. Disparate results on the surgical treatment of phCC made it impossible to reach clear-cut conclusions.
Collapse
Affiliation(s)
- Alejandro Serrablo
- Section of Surgery, European Union of Medical Specialists, 1040 Brussels, Belgium
- HPB Surgical Division, Miguel Servet University Hospital, Zaragoza University, 50009 Zaragoza, Spain
| | - Leyre Serrablo
- Medicine School, Zaragoza University, 50009 Zaragoza, Spain;
| | - Ruslan Alikhanov
- Division of Liver and Pancreatic Surgery, Moscow Clinical Research Center, 111123 Moscow, Russia;
| | - Luis Tejedor
- Department of Surgery, Punta Europa Hospital, 11207 Algeciras, Spain;
| |
Collapse
|
|
29
|
Bednarsch J, Czigany Z, Heij LR, Luedde T, Wiltberger G, Dulk MD, Bruners P, Lang SA, Ulmer TF, Neumann UP. The prognostic role of tumor-associated unilateral portal vein occlusion in perihilar cholangiocarcinoma. HPB (Oxford) 2021; 23:1565-1577. [PMID: 33934958 DOI: 10.1016/j.hpb.2021.03.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 03/17/2021] [Accepted: 03/30/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND While a certain degree of tumor infiltration of the portal vein is common in patients with perihilar cholangiocarcinoma (pCCA) scheduled for surgery, complete tumor-associated portal vein occlusion (PVO) is less frequently observed. Here, we analyzed the impact of PVO on perioperative and oncological outcomes in pCCA patients. METHODS Between 2010 and 2019, 127 patients with pCCA underwent surgery in curative intent at our department of which 17.3% (22/127) presented with PVO. Extensive group comparisons were conducted and the association of cancer-specific (CSS) and disease-free survival (DFS) with PVO and other clinico-pathological characteristics were assessed using Cox regression models. RESULTS Patients without PVO showed a median CSS of 65 months (3-year-CSS = 64%, 5-year-CSS = 53%) compared to 31 months (3-year-CSS = 43%, 5-year-CSS = 17%) in patients with PVO (p = 0.025 log rank). Patients with PVO did also display significant perioperative mortality (22.7%, 5/22) compared to patients without PVO (14.3%, 15/105, p = 0.323). Further, PVO (CSS: HR = 5.25, p = 0.001; DFS: HR = 5.53, p = 0.001) was identified as independent predictors of oncological outcome. CONCLUSIONS PVO has been identified as an important prognostic marker playing a role in inferior oncological outcome in patients with pCCA. As PVO is also associated with notable perioperative mortality, surgical therapy should be considered carefully in pCCA patients.
Collapse
Affiliation(s)
- Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Lara R Heij
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany; Institute of Pathology, University Hospital RWTH Aachen, Aachen, Germany
| | - Tom Luedde
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, University Hospital RWTH Aachen, Aachen, Germany; Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Heinrich Heine University Duesseldorf, Germany
| | - Georg Wiltberger
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Marcel den Dulk
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany; Department of Surgery, Maastricht University Medical Center (MUMC), Maastricht, Netherlands
| | - Philipp Bruners
- Department of Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Sven A Lang
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Tom F Ulmer
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Ulf P Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany; Department of Surgery, Maastricht University Medical Center (MUMC), Maastricht, Netherlands.
| |
Collapse
|
|
30
|
Hau HM, Devantier M, Jahn N, Sucher E, Rademacher S, Seehofer D, Sucher R. Impact of Body Mass Index on Tumor Recurrence in Patients Undergoing Liver Resection for Perihilar Cholangiocarcinoma (pCCA). Cancers (Basel) 2021; 13:cancers13194772. [PMID: 34638257 PMCID: PMC8507532 DOI: 10.3390/cancers13194772] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 09/21/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Perihilar cholangiocarcinoma (pCCA) is a relatively rare and aggressive hepatobiliary tumor with a general poor prognosis. Surgical therapy remains the only curative treatment option with the best prospects for long-term survival. However, tumor recurrence is frequent, and is associated with a poor prognosis. The identification of risk factors as well as appropriate selection of surgical candidates is essential to accurately predict prognosis and to maximize survival while decreasing tumor recurrence rates. Previous studies have already established a link between an increased BMI and the occurrence of various tumors. At present, data on BMI-associated long-term outcome following curative liver resection in pCCA patients are warranted. This study aims to investigate the impact of increased BMI on patient’s outcome, especially on tumor recurrence, following liver resection in patients with pCCA as well as to evaluate prognostic and risk factors for accurate prediction of outcome in this selective group of patients. Abstract Background: The association of body mass index (BMI) and long-term prognosis and outcome of patients with perihilar cholangiocarcinoma (pCCA) has not been well defined. The aim of this study was to evaluate clinicopathologic and oncologic outcomes with pCCA undergoing resection, according to their BMI. Methods: Patients undergoing liver resection in curative intention for pCCA at a tertiary German hepatobiliary (HPB) center were identified from a prospective database. Patients were classified as normal weight (BMI 18.5–24.9 kg/m2), overweight (BMI 25.0–29.9 kg/m2) and obese (>30 kg/m2) according to their BMI. Impact of clinical and histo-pathological characteristics on recurrence-free survival (RFS) were assessed using Cox proportional hazard regression analysis among patients of all BMI groups. Results: Among a total of 95 patients undergoing liver resection in curative intention for pCCA in the analytic cohort, 48 patients (50.5%) had normal weight, 33 (34.7%) were overweight and 14 patients (14.7%) were obese. After a median follow-up of 4.3 ± 2.9 years, recurrence was observed in totally 53 patients (56%). The cumulative recurrence probability was higher in obese and overweight patients than normal weight patients (5-year recurrence rate: obese: 82% versus overweight: 81% versus normal weight: 58% at 5 years; p = 0.02). Totally, 1-, 3-, 5- and 10-year recurrence-free survival rates were 68.5%, 44.6%, 28.9% and 13%, respectively. On multivariable analysis, increased BMI (HR 1.08, 95% CI: 1.01–1.16; p = 0.021), poor/moderate tumor differentiation (HR 2.49, 95% CI: 1.2–5.2; p = 0.014), positive lymph node status (HR 2.01, 95% CI: 1.11–3.65; p = 0.021), positive resection margins (HR 1.89, 95% CI:1.02–3.4; p = 0.019) and positive perineural invasion (HR 2.92, 95% CI: 1.02–8.3; p = 0.045) were independent prognostic risk factors for inferior RFS. Conclusion: Our study shows that a high BMI is significantly associated with an increased risk of recurrence after liver resection in curative intention for pCCA. This factor should be considered in future studies to better predict patient’s individual prognosis and outcome based on their BMI.
Collapse
Affiliation(s)
- Hans-Michael Hau
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany; (H.-M.H.); (M.D.); (S.R.); (D.S.)
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Mareen Devantier
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany; (H.-M.H.); (M.D.); (S.R.); (D.S.)
| | - Nora Jahn
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Leipzig, 04103 Leipzig, Germany;
| | - Elisabeth Sucher
- Department of Oncology, Gastroenterology, Hepatology, Pneumology, Infectiology, and Nutritional Medicine, University Hospital of Leipzig, 04103 Leipzig, Germany;
| | - Sebastian Rademacher
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany; (H.-M.H.); (M.D.); (S.R.); (D.S.)
| | - Daniel Seehofer
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany; (H.-M.H.); (M.D.); (S.R.); (D.S.)
| | - Robert Sucher
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, 04103 Leipzig, Germany; (H.-M.H.); (M.D.); (S.R.); (D.S.)
- Correspondence: ; Tel.: +49-(0)341-9720-860; Fax: +49-(0)341-9717-209
| |
Collapse
|
|
31
|
Liu Y, Li G, Lu Z, Wang T, Yang Y, Wang X, Liu J. Effect of vascular resection for perihilar cholangiocarcinoma: a systematic review and meta-analysis. PeerJ 2021; 9:e12184. [PMID: 34631316 PMCID: PMC8466000 DOI: 10.7717/peerj.12184] [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: 04/29/2021] [Accepted: 08/29/2021] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To evaluate the effect of vascular resection (VR), including portal vein resection (PVR) and hepatic artery resection (HAR), on short- and long-term outcomes in patients with perihilar cholangiocarcinoma (PHC). BACKGROUND Resection surgery and transplantation are the main treatment methods for PHC that provide a chance of long-term survival. However, the efficacy and safety of VR, including PVR and HAR, for treating PHC remain controversial. METHODS This study was registered at the International Prospective Register of Systematic Reviews (CRD42020223330). The EMBASE, PubMed, and Cochrane Library databases were used to search for eligible studies published through November 28, 2020. Studies comparing short- and long-term outcomes between patients who underwent hepatectomy with or without PVR and/or HAR were included. Random- and fixed-effects models were applied to assess the outcomes, including morbidity, mortality, and R0 resection rate, as well as the impact of PVR and HAR on long-term survival. RESULTS Twenty-two studies including 4,091 patients were deemed eligible and included in this study. The meta-analysis showed that PVR did not increase the postoperative morbidity rate (odds ratio (OR): 1.03, 95% confidenceinterval (CI): [0.74-1.42], P = 0.88) and slightly increased the postoperative mortality rate (OR: 1.61, 95% CI [1.02-2.54], P = 0.04). HAR did not increase the postoperative morbidity rate (OR: 1.32, 95% CI [0.83-2.11], P = 0.24) and significantly increased the postoperative mortality rate (OR: 4.20, 95% CI [1.88-9.39], P = 0.0005). Neither PVR nor HAR improved the R0 resection rate (OR: 0.70, 95% CI [0.47-1.03], P = 0.07; OR: 0.77, 95% CI [0.37-1.61], P = 0.49, respectively) or long-term survival (OR: 0.52, 95% CI [0.35-0.76], P = 0.0008; OR: 0.43, 95% CI [0.32-0.57], P < 0.00001, respectively). CONCLUSIONS PVR is relatively safe and might benefit certain patients with advanced PHC in terms of long-term survival, but it is not routinely recommended. HAR results in a higher mortality rate and lower overall survival rate, with no proven benefit.
Collapse
Affiliation(s)
- Yong Liu
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, China
| | - Guangbing Li
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, China
| | - Ziwen Lu
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, China
| | - Tao Wang
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, China
| | - Yang Yang
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, China
| | - Xiaoyu Wang
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, China
| | - Jun Liu
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, China
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, China
| |
Collapse
|
|
32
|
Bednarsch J, Czigany Z, Heij LR, Luedde T, Loosen SH, Dulk MD, Bruners P, Lang SA, Ulmer TF, Neumann UP. The prognostic role of in-hospital transfusion of fresh frozen plasma in patients with cholangiocarcinoma undergoing curative-intent liver surgery. Eur J Surg Oncol 2021; 48:604-614. [PMID: 34565633 DOI: 10.1016/j.ejso.2021.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 09/12/2021] [Accepted: 09/15/2021] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Major hepatectomy for perihilar and intrahepatic cholangiocarcinoma (CCA) is often associated with a significant intraoperative blood loss and the requirement for perioperative transfusion of blood products. The aim of this study was to investigate the oncological impact of fresh frozen plasma (FFP) transfusion during hospitalization in patients undergoing hepatectomy for CCA as adverse effects have been described in other malignancies. MATERIAL AND METHODS Patients undergoing hepatectomy for CCA from 2010 to 2019 at a single institution were eligible for this study. Survival analysis was carried out according to Kaplan-Meier and the associations of cancer-specific (CSS) and recurrence-free survival (RFS) with in-hospital application of FFP and other clinico-pathological characteristics were assessed using Cox regression models. Perioperatively deceased patients were excluded from the analysis. RESULTS A total of 219 CCA patients were included in this survival analysis of which 53.0% (116/219) received FFP during hospitalization. Patients receiving in-hospital FFP showed a median CCS of 33 months (3-year-CSS = 46%, 5-year-CSS = 29%) compared to 83 months (3-year-CSS = 55%, 5-year-CSS = 53%) in patients who did not receive in-hospital FFP (p = 0.006 log rank). Further, in-hospital FFP was identified as an independent predictor of oncological outcome in multivariable analysis (CSS: HR = 1.71, p = 0.016; RFS: HR = 1.89, p = 0.003). CONCLUSION In a large European cohort of patients, in-hospital transfusion of FFP was identified as a novel independent prognostic marker in CCA patients undergoing curative-intent liver surgery. A restrictive transfusion policy is therefore recommended to improve long-term outcome in these patients.
Collapse
Affiliation(s)
- Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Lara R Heij
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany; Institute of Pathology, University Hospital RWTH Aachen, Aachen, Germany
| | - Tom Luedde
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Sven H Loosen
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Marcel den Dulk
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany; Department of Surgery, Maastricht University Medical Center (MUMC), Maastricht, Netherlands
| | - Philipp Bruners
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Sven A Lang
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Tom F Ulmer
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Ulf P Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany; Department of Surgery, Maastricht University Medical Center (MUMC), Maastricht, Netherlands.
| |
Collapse
|
|
33
|
Bednarsch J, Czigany Z, Loosen SH, Heij L, Ruckgaber L, Maes H, Krause JP, Reen M, Toteva B, Vosdellen T, Bruners P, Lang SA, Ulmer TF, Roderburg C, Luedde T, Neumann UP. Perioperative rifaximin is not associated with enhanced functional and volumetric recovery after major liver resection. Sci Rep 2021; 11:17936. [PMID: 34504196 PMCID: PMC8429542 DOI: 10.1038/s41598-021-97442-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 08/18/2021] [Indexed: 02/07/2023] Open
Abstract
The objective of this randomized controlled trial (RCT) was to assess the impact of rifaximin on the course of liver function, liver regeneration and volumetric recovery in patients undergoing major hepatectomy. The ARROW trial was an investigator initiated, single-center, open-label, phase 3 RCT with two parallel treatment groups, conducted at our hepatobiliary center from 03/2016 to 07/2020. Patients undergoing major hepatectomy were eligible and randomly assigned 1:1 to receive oral rifaximin (550 mg twice daily for 7-10 or 14-21 days in case of portal vein embolization preoperatively and 7 days postoperatively) versus no intervention. Primary endpoint was the relative increase in postoperative liver function measured by LiMAx from postoperative day (POD) 4 to 7. Secondary endpoint were the course of liver function and liver volume during the study period as well as postoperative morbidity and mortality. Between 2016 and 2020, 45 patients were randomized and 35 patients (16 individuals in the rifaximin and 19 individuals in the control group) were eligible for per-protocol analysis. The study was prematurely terminated following interim analysis, due to the unlikelihood of reaching a significant primary endpoint. The median relative increase in liver function from POD 4 to POD 7 was 27% in the rifaximin group and 41% in the control group (p = 0.399). Further, no significant difference was found in terms of any other endpoints of functional liver- and volume regeneration or perioperative surgical complications following the application of rifaximin versus no intervention. Perioperative application of rifaximin has no effect on functional or volumetric regeneration after major hepatectomy (NCT02555293; EudraCT 2013-004644-28).
Collapse
Affiliation(s)
- Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Sven H Loosen
- Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Heinrich Heine University, Duesseldorf, Germany
| | - Lara Heij
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
- Institute of Pathology, University Hospital RWTH Aachen, Aachen, Germany
| | - Lorenz Ruckgaber
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Henning Maes
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Jan-Pit Krause
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Matthias Reen
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Beata Toteva
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Theresa Vosdellen
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Philipp Bruners
- Department of Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Sven Arke Lang
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Tom Florian Ulmer
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Christoph Roderburg
- Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Heinrich Heine University, Duesseldorf, Germany
| | - Tom Luedde
- Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Heinrich Heine University, Duesseldorf, Germany
| | - Ulf Peter Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany.
- Department of Surgery, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands.
| |
Collapse
|
|
34
|
Oncological Superiority of Right-sided Hepatectomy Over Left-sided Hepatectomy as Surgery for Perihilar Cholangiocarcinoma: Truth or Biased View? Ann Surg 2021; 274:31-32. [PMID: 33214439 DOI: 10.1097/sla.0000000000004534] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
|
35
|
Sugiura T, Uesaka K, Okamura Y, Ito T, Yamamoto Y, Ashida R, Ohgi K, Otsuka S, Nakagawa M, Aramaki T, Asakura K. Major hepatectomy with combined vascular resection for perihilar cholangiocarcinoma. BJS Open 2021; 5:6342603. [PMID: 34355240 PMCID: PMC8342931 DOI: 10.1093/bjsopen/zrab064] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 05/31/2021] [Indexed: 12/14/2022] Open
Abstract
Background Hepatectomy with vascular resection (VR) for perihilar cholangiocarcinoma (PHCC) is a challenging procedure. However, only a few reports on this procedure have been published and its clinical significance has not been fully evaluated. Methods Patients undergoing surgical resection for PHCC from 2002–2017 were studied. The surgical outcomes of VR and non-VR groups were compared. Results Some 238 patients were included. VR was performed in 85 patients. The resected vessels were hepatic artery alone (31 patients), portal vein alone (37 patients) or both (17 patients). The morbidity rates were almost the same in the VR (49.4 per cent) and non-VR (43.8 per cent) groups (P = 0.404). The mortality rates of VR (3.5 per cent) and non-VR (3.3 per cent) were also comparable (P > 0.999). The median survival time (MST) was 45 months in the non-VR group and 36 months in VR group (P = 0.124). Among patients in whom tumour involvement was suspected on preoperative imaging and whose carbohydrate antigen 19-9 (CA19-9) value was 37 U/ml or less, MST in the VR group was significantly longer than that in the non-VR group (50 versus 34 months, P = 0.017). In contrast, when the CA19-9 value was greater than 37 U/ml, MST of the VR and non-VR groups was comparable (28 versus 29 months, P = 0.520). Conclusion Hepatectomy with VR for PHCC can be performed in a highly specialized hepatobiliary centre with equivalent short- and long-term outcomes to hepatectomy without VR.
Collapse
Affiliation(s)
- T Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery
| | - K Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery
| | - Y Okamura
- Division of Hepato-Biliary-Pancreatic Surgery
| | - T Ito
- Division of Hepato-Biliary-Pancreatic Surgery
| | - Y Yamamoto
- Division of Hepato-Biliary-Pancreatic Surgery
| | - R Ashida
- Division of Hepato-Biliary-Pancreatic Surgery
| | - K Ohgi
- Division of Hepato-Biliary-Pancreatic Surgery
| | - S Otsuka
- Division of Hepato-Biliary-Pancreatic Surgery
| | - M Nakagawa
- Division of Plastic and Reconstructive Surgery
| | - T Aramaki
- Division of Diagnostic Radiology, Shizuoka Cancer Centre, Shizuoka, Japan
| | - K Asakura
- Division of Diagnostic Radiology, Shizuoka Cancer Centre, Shizuoka, Japan
| |
Collapse
|
|
36
|
Angelico R, Sensi B, Parente A, Siragusa L, Gazia C, Tisone G, Manzia TM. Vascular Involvements in Cholangiocarcinoma: Tips and Tricks. Cancers (Basel) 2021; 13:3735. [PMID: 34359635 PMCID: PMC8345051 DOI: 10.3390/cancers13153735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/15/2021] [Accepted: 07/19/2021] [Indexed: 01/04/2023] Open
Abstract
Cholangiocarcinoma (CCA) is an aggressive malignancy of the biliary tract. To date, surgical treatment remains the only hope for definitive cure of CCA patients. Involvement of major vascular structures was traditionally considered a contraindication for resection. Nowadays, selected cases of CCA with vascular involvement can be successfully approached. Intrahepatic CCA often involves the major hepatic veins or the inferior vena cava and might necessitate complete vascular exclusion, in situ hypothermic perfusion, ex situ surgery and reconstruction with autologous, heterologous or synthetic grafts. Hilar CCA more frequently involves the portal vein and hepatic artery. Resection and reconstruction of the portal vein is now considered a relatively safe and beneficial technique, and it is accepted as a standard option either with direct anastomosis or jump grafts. However, hepatic artery resection remains controversial; despite accumulating positive reports, the procedure remains technically challenging with increased rates of morbidity. When arterial reconstruction is not possible, arterio-portal shunting may offer salvage, while sometimes an efficient collateral system could bypass the need for arterial reconstructions. Keys to achieve success are represented by accurate selection of patients in high-volume referral centres, adequate technical skills and eclectic knowledge of the various possibilities for vascular reconstruction.
Collapse
Affiliation(s)
- Roberta Angelico
- Hepatobiliary Surgery and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy; (R.A.); (B.S.); (A.P.); (L.S.); (C.G.); (T.M.M.)
| | - Bruno Sensi
- Hepatobiliary Surgery and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy; (R.A.); (B.S.); (A.P.); (L.S.); (C.G.); (T.M.M.)
| | - Alessandro Parente
- Hepatobiliary Surgery and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy; (R.A.); (B.S.); (A.P.); (L.S.); (C.G.); (T.M.M.)
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital, Birmingham B15 2TH, UK
| | - Leandro Siragusa
- Hepatobiliary Surgery and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy; (R.A.); (B.S.); (A.P.); (L.S.); (C.G.); (T.M.M.)
| | - Carlo Gazia
- Hepatobiliary Surgery and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy; (R.A.); (B.S.); (A.P.); (L.S.); (C.G.); (T.M.M.)
| | - Giuseppe Tisone
- Hepatobiliary Surgery and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy; (R.A.); (B.S.); (A.P.); (L.S.); (C.G.); (T.M.M.)
| | - Tommaso Maria Manzia
- Hepatobiliary Surgery and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy; (R.A.); (B.S.); (A.P.); (L.S.); (C.G.); (T.M.M.)
| |
Collapse
|
|
37
|
Lauterio A, De Carlis R, Centonze L, Buscemi V, Incarbone N, Vella I, De Carlis L. Current Surgical Management of Peri-Hilar and Intra-Hepatic Cholangiocarcinoma. Cancers (Basel) 2021; 13:3657. [PMID: 34359560 PMCID: PMC8345178 DOI: 10.3390/cancers13153657] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/06/2021] [Accepted: 07/19/2021] [Indexed: 01/17/2023] Open
Abstract
Cholangiocarcinoma accounts for approximately 10% of all hepatobiliary tumors and represents 3% of all new-diagnosed malignancies worldwide. Intrahepatic cholangiocarcinoma (i-CCA) accounts for 10% of all cases, perihilar (h-CCA) cholangiocarcinoma represents two-thirds of the cases, while distal cholangiocarcinoma accounts for the remaining quarter. Originally described by Klatskin in 1965, h-CCA represents one of the most challenging tumors for hepatobiliary surgeons, mainly because of the anatomical vascular relationships of the biliary confluence at the hepatic hilum. Surgery is the only curative option, with the goal of a radical, margin-negative (R0) tumor resection. Continuous efforts have been made by hepatobiliary surgeons in order to achieve R0 resections, leading to the progressive development of aggressive approaches that include extended hepatectomies, associating liver partition, and portal vein ligation for staged hepatectomy, pre-operative portal vein embolization, and vascular resections. i-CCA is an aggressive biliary cancer that arises from the biliary epithelium proximal to the second-degree bile ducts. The incidence of i-CCA is dramatically increasing worldwide, and surgical resection is the only potentially curative therapy. An aggressive surgical approach, including extended liver resection and vascular reconstruction, and a greater application of systemic therapy and locoregional treatments could lead to an increase in the resection rate and the overall survival in selected i-CCA patients. Improvements achieved over the last two decades and the encouraging results recently reported have led to liver transplantation now being considered an appropriate indication for CCA patients.
Collapse
Affiliation(s)
- Andrea Lauterio
- Department of General Surgery and Transplantation, Niguarda Ca’ Granda Hospital, 20162 Milan, Italy; (A.L.); (R.D.C.); (V.B.); (N.I.); (I.V.); (L.D.C.)
| | - Riccardo De Carlis
- Department of General Surgery and Transplantation, Niguarda Ca’ Granda Hospital, 20162 Milan, Italy; (A.L.); (R.D.C.); (V.B.); (N.I.); (I.V.); (L.D.C.)
| | - Leonardo Centonze
- Department of General Surgery and Transplantation, Niguarda Ca’ Granda Hospital, 20162 Milan, Italy; (A.L.); (R.D.C.); (V.B.); (N.I.); (I.V.); (L.D.C.)
| | - Vincenzo Buscemi
- Department of General Surgery and Transplantation, Niguarda Ca’ Granda Hospital, 20162 Milan, Italy; (A.L.); (R.D.C.); (V.B.); (N.I.); (I.V.); (L.D.C.)
| | - Niccolò Incarbone
- Department of General Surgery and Transplantation, Niguarda Ca’ Granda Hospital, 20162 Milan, Italy; (A.L.); (R.D.C.); (V.B.); (N.I.); (I.V.); (L.D.C.)
- School of Medicine and Surgery, University of Milano-Bicocca, 20162 Milan, Italy
| | - Ivan Vella
- Department of General Surgery and Transplantation, Niguarda Ca’ Granda Hospital, 20162 Milan, Italy; (A.L.); (R.D.C.); (V.B.); (N.I.); (I.V.); (L.D.C.)
- Department of Surgical Sciences, University of Pavia, 27100 Pavia, Italy
| | - Luciano De Carlis
- Department of General Surgery and Transplantation, Niguarda Ca’ Granda Hospital, 20162 Milan, Italy; (A.L.); (R.D.C.); (V.B.); (N.I.); (I.V.); (L.D.C.)
- School of Medicine and Surgery, University of Milano-Bicocca, 20162 Milan, Italy
- International Center for Digestive Health, University of Milano-Bicocca, 20162 Milan, Italy
| |
Collapse
|
|
38
|
Bednarsch J, Kather J, Tan X, Sivakumar S, Cacchi C, Wiltberger G, Czigany Z, Ulmer F, Neumann UP, Heij LR. Nerve Fibers in the Tumor Microenvironment as a Novel Biomarker for Oncological Outcome in Patients Undergoing Surgery for Perihilar Cholangiocarcinoma. Liver Cancer 2021; 10:260-274. [PMID: 34239812 PMCID: PMC8237795 DOI: 10.1159/000515303] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/12/2021] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Perihilar cholangiocarcinoma (pCCA) is a biliary tract cancer with a dismal prognosis, with surgery being the only chance of cure. A characteristic aggressive biological feature of pCCA is perineural growth which is defined by the invasion of cancer cells to nerves and nerve fibers. Recently, nerve fiber density (NFD) was linked to oncological outcomes in various malignancies; however, its prognostic role in pCCA remains to be elucidated. MATERIALS AND METHODS Data of 101 pCCA patients who underwent curative-intent surgery between 2010 and 2019 were included in this study. Extensive group comparisons between patients with high and low NFD were carried out, and the association of cancer-specific survival (CSS) and recurrence-free survival with NFD and other clinicopathological characteristics was assessed using univariate and multivariable cox regression models. RESULTS Patients with high NFD showed a median CSS of 90 months (95% CI: 48-132, 3-year CSS = 77%, 5-year CSS = 72%) compared to 33 months (95% CI: 19-47, 3-year CSS = 46%, 5-year CSS = 32%) in patients with low NFD (p = 0.006 log rank). Further, N1 category (HR = 2.84, p = 0.001) and high NFD (HR = 0.41, p = 0.024) were identified as independent predictors of CSS in multivariable analysis. Patients with high NFD and negative lymph nodes showed a median CSS of 90 months (3-year CSS = 88%, 5-year CSS = 80%), while patients with either positive lymph nodes or low NFD displayed a median CSS of 51 months (3-year CSS = 59%, 5-year CSS = 45%) and patients with both positive lymph nodes and low NFD a median CSS of 24 months (3-year CSS = 26%, 5-year CSS = 16%, p = 0.001 log rank). CONCLUSION NFD has been identified as an important novel prognostic biomarker in pCCA patients. NFD alone and in combination with nodal status in particular allows to stratify pCCA patients based on their risk for inferior oncological outcomes after curative-intent surgery.
Collapse
Affiliation(s)
- Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Jakob Kather
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Xiuxiang Tan
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany,Department of Surgery, Maastricht University Medical Center (MUMC), Maastricht, The Netherlands,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Shivan Sivakumar
- Department of Oncology, University of Oxford, Oxford, United Kingdom,Kennedy Institute of Rheumatology, University of Oxford, Oxford, United Kingdom
| | - Claudio Cacchi
- Institute of Pathology, University Hospital RWTH Aachen, Aachen, Germany
| | - Georg Wiltberger
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Florian Ulmer
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Ulf Peter Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany,Department of Surgery, Maastricht University Medical Center (MUMC), Maastricht, The Netherlands
| | - Lara Rosaline Heij
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands,Institute of Pathology, University Hospital RWTH Aachen, Aachen, Germany,*Lara Rosaline Heij,
| |
Collapse
|
|
39
|
A tailored approach in lymph node-positive perihilar cholangiocarcinoma. Langenbecks Arch Surg 2021; 406:1499-1509. [PMID: 34075473 PMCID: PMC8370897 DOI: 10.1007/s00423-021-02154-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/18/2021] [Indexed: 01/04/2023]
Abstract
Purpose Extended right hepatectomy is associated with wide surgical margins in PHC and often favored for oncological considerations. However, it remains uncertain whether established surgical principles also apply to the subgroup of node-positive patients. The aim of the present study was to define a tailored surgical approach for patients with perihilar cholangiocarcinoma (PHC) and lymph node metastases. Methods We reviewed the course of all consecutive patients undergoing major hepatectomy for PHC between 2005 and 2015 at the Department of Surgery, Charité – Universitätsmedizin Berlin. Results Two hundred and thirty-one patients underwent major hepatectomy for PHC with 1-, 3-, and 5-year overall (OS) and disease-free survival (DFS) rates of 72%, 48%, and 36%, and 60%, 22%, and 12%, respectively. In lymph node-positive patients (n = 109, 47%), extended left hepatectomy was associated with improved OS and DFS, respectively, when compared to extended right hepatectomy (p = 0.008 and p = 0.003). Interestingly, OS and DFS did not differ between R0 and R1 resections in those patients (both p = ns). Patients undergoing extended left hepatectomy were more likely to receive adjuvant chemotherapy (p = 0.022). This is of note as adjuvant chemotherapy, besides grading (p = 0.041), was the only independent prognostic factor in node-positive patients (p=0.002). Conclusion Patients with node-positive PHC might benefit from less aggressive approaches being associated with lower morbidity and a higher chance for adjuvant chemotherapy. Lymph node sampling might help to guide patients to the appropriate surgical approach according to their lymph node status. Supplementary Information The online version contains supplementary material available at 10.1007/s00423-021-02154-4.
Collapse
|
|
40
|
Wu W, Cheng Q, Chen J, Chen D, Feng X, Wu J. Left-side vs. right-side hepatectomy for hilar cholangiocarcinoma: a meta-analysis. World J Surg Oncol 2021; 19:107. [PMID: 33838682 PMCID: PMC8037893 DOI: 10.1186/s12957-021-02213-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/23/2021] [Indexed: 02/08/2023] Open
Abstract
GOALS We aim to draw a conclusion which type of hepatectomy could be the priority for hilar cholangiocarcinoma patients. BACKGROUND Surgery is established as only potentially curative treatment for hilar cholangiocarcinoma. However, whether hepatectomy should be preferred to the left-side hepatectomy, which includes left hemihepatectomy, extended left hemihepatectomy, and left trisectionectomy, or right-side hepatectomy, which represents right hemihepatectomy, extended right hemihepatectomy, and right trisectionectomy, is debated. In this meta-analysis, we evaluated and compared the efficacy and safety of left-side hepatectomy and right-side hepatectomy in patients with hilar cholangiocarcinoma. STUDY We systematically retrieved the MEDLINE, PubMed, and Cochrane library and related bibliography up to February 2020. The primary outcome is overall survival, and the secondary outcome includes 1-, 3-, and 5-year survival rates, morbidity, mortality, R0 resection rate, and operation time. Based on heterogeneity, fixed-effects model or random-effects models were established through meta-analysis. RESULTS Eleven studies (11 cohort studies, totally 1031 patients) were involved in this study. The overall survival of patients who underwent left-side hepatectomy was comparable to that of patients who underwent right-side hepatectomy (hazard ratio, 1.27 [95% confidence interval, 0.98-1.63]). And there was no significant difference observed in 1-year (relative risk, 1.01 [95% CI, 0.89-1.15]), 3-year (relative risk, 0.94 [95% confidence interval, 0.80-1.11]), and 5-year survival (relative risk, 0.82 [95% confidence interval, 0.67-1.01]) rates between the left-side hepatectomy group and the right-side hepatectomy group. Comparing with the right-side hepatectomy cluster, the hilar cholangiocarcinoma patients in the left-side hepatectomy cluster presented better overall postoperative morbidity (relative risk, 0.82 [95% confidence interval, 0.71-0.96]) and major postoperative morbidity (relative risk, 0.73 [95% confidence interval, 0.56-0.95]). The post-hepatectomy liver failure rate (relative risk, 0.22 [95% confidence interval, 0.09-0.56]) and procedure-related mortality (relative risk, 0.41 [95% confidence interval, 0.23-0.70]) in the left-side hepatectomy group were better than those of the right-side hepatectomy group. Besides, the R0 resection rate was similar between the left-side hepatectomy group and the right-side hepatectomy group (relative risk, 0.95 [95% confidence interval, 0.87-1.03]). And the operation time for the left-side hepatectomy was significantly longer than that for the right-side hepatectomy (mean difference, 38.68 [95% confidence interval, 7.41-69.95]). CONCLUSION Through meta-analysis, we explored the comparable long-term outcomes and better short-term outcomes in the left-side hepatectomy group as is compared to the right-side hepatectomy group of hilar cholangiocarcinoma patients. In this study, the evidence obtained might indicate that the choice of left-side hepatectomy or right-side hepatectomy depends on the site of hilar cholangiocarcinoma in every patient.
Collapse
Affiliation(s)
- Wenxuan Wu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, Zhejiang Province, China
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Qiyang Cheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, Zhejiang Province, China
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Junru Chen
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, Zhejiang Province, China
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Diyu Chen
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, Zhejiang Province, China
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Xiaode Feng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, Zhejiang Province, China
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Jian Wu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, Zhejiang Province, China.
- Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China.
- Key Laboratory of Organ Transplantation, Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, Hangzhou, 310003, Zhejiang Province, China.
| |
Collapse
|
|
41
|
Soares KC, Jarnagin WR. The Landmark Series: Hilar Cholangiocarcinoma. Ann Surg Oncol 2021; 28:4158-4170. [PMID: 33829358 DOI: 10.1245/s10434-021-09871-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/01/2021] [Indexed: 12/15/2022]
Abstract
Hilar cholangiocarcinoma (HC) is a rare and highly aggressive biliary tract neoplasm. As such, the data driving the management of this disease generally are not based on prospective clinical trial data but rather consist of retrospective experiences and limited level 1 data. Surgical resection offers the best chance of a long-term survival, but local and distant recurrences are common. This report presents landmark articles that form the basis of preoperative, operative, and adjuvant strategies for HC.
Collapse
Affiliation(s)
- Kevin C Soares
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Surgery, Weill Cornell Medical College, New York, NY, USA
| | - William R Jarnagin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA. .,Department of Surgery, Weill Cornell Medical College, New York, NY, USA.
| |
Collapse
|
|
42
|
Franken LC, Olthof PB, Erdmann JI, van Delden OM, Verheij J, Besselink MG, Busch OR, van Gulik TM. Short- and long-term outcomes after hemihepatectomy for perihilar cholangiocarcinoma: does left or right side matter? Hepatobiliary Surg Nutr 2021; 10:154-162. [PMID: 33898556 DOI: 10.21037/hbsn-19-948] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background The only potentially curative option for patients with perihilar cholangiocarcinoma (PHC) is resection, typically an extrahepatic bile duct resection in combination with (extended) liver resection. Complications such as bile leakage and liver failure have been suggested to be more common after right-sided resections compared to left-sided resections, whilst superior oncological outcomes have been reported after right-sided resections. However, data on outcomes after right-sided or left-sided liver resections in PHC are scarce. Therefore, we aimed to investigate short- and long-term outcomes after left and right hemihepatectomy in patients with PHC. Methods In this retrospective study, patients undergoing major liver resection for suspected PHC in a tertiary center between 2000-2018 were included. Patients who had undergone left-sided resections were compared to patients with right-sided resections in terms of complications (90-day mortality, overall and severe morbidity and specific complications). For long-term outcomes, only patients with pathologically proven PHC were included in the survival analysis. Results A total of 178 patients undergoing hemihepatectomy for suspected PHC were analysed, including 76 left-sided and 102 right-sided resections. Overall 90-day mortality was 14% (24 out of 178), with no significant difference after left-sided resection (11%; 8 out of 76) versus right-sided resection (16%; 16 out of 102) (P=0.319). Severe morbidity (Clavein Dindo ≥3) was also comparable in both groups: 54% versus 61% (P=0.361). No differences in specific complications including bile leakage were observed, although liver failure appeared to occur more frequently after right hemihepatectomy (22% versus 11%, P=0.052). Five-year overall survival for pathologically proven PHC, excluding in-hospital mortality, did not differ; 43.7% after left-sided resection vs. and 38.2% after right-sided resection (P=0.553). Conclusions Both short- and long-term outcomes between patients undergoing left and right hemihepatectomy for PHC were comparable. Post-hepatectomy liver failure was more common after right-sided resection.
Collapse
Affiliation(s)
- Lotte C Franken
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Pim B Olthof
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands.,Department of Surgery, Erasmus Medical Center, Erasmus University, Rotterdam, The Netherlands
| | - Joris I Erdmann
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Otto M van Delden
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joanne Verheij
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| |
Collapse
|
|
43
|
Golse N, Nunez J, Mazzotta A, Cano L, Bergeat D, Sulpice L, Jeddou H, Abdelrafee A, Sa Cunha A, Cherqui D, Adam R, Boudjema K, Vibert E. Personalized Preoperative Nomograms Predicting Postoperative Risks after Resection of Perihilar Cholangiocarcinoma. World J Surg 2021; 44:3449-3460. [PMID: 32474628 DOI: 10.1007/s00268-020-05618-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Curative treatment of perihilar tumors requires major hepatectomy responsible for high morbidity and mortality. Current nomograms are based on definitive pathological analysis, not usable for patient selection. Our aim was to propose preoperative predictors for severe morbidity (Dindo-Clavien ≥3) and mortality at sixth month after resection of perihilar tumors. PATIENTS AND METHODS We reviewed perioperative data of 186 patients operated with major hepatectomy for perihilar tumors between 2012 and 2018 in two high-volume centers. Univariate and multivariate analysis were performed to determine the preoperative predictors of morbidity and mortality. A stepwise regression in forward direction was developed to select variables for definitive models. Hosmer-Lemeshow test, Akaike information criteria and area under the ROC curves were calculated to validate both nomograms. RESULTS Resections were indicated for perihilar and intrahepatic cholangiocarcinoma in 125 and 61 cases, respectively. Severe complications occurred in 76 patients (40.8%). Nineteen patients (10.2%) deceased before the sixth postoperative month. The predictors of severe morbidity were: male gender, portal vein embolization, planned biliary resection, low psoas muscle area/height2 and low hemoglobinemia. The predictors of early mortality were: age, high bilirubinemia, hypoalbuminemia, biliary drainage and long drainage-to-surgery interval. For both models, the p values of Hosmer-Lemeshow tests were of 0.9 and 0.99, respectively, the Akaike information criteria were of 35.5 and 37.7, respectively, and area under the curves was of 0.73 and 0.86, respectively. CONCLUSION We developed two accurate and practical nomograms based on exclusively preoperative data to predict early outcomes following the resection of perihilar tumors. If validated in larger series, these tools could be integrated in the decision-making process for patient selection.
Collapse
Affiliation(s)
- Nicolas Golse
- Department of Surgery, Assistance Publique Hôpitaux de Paris, Paul-Brousse Hospital, Centre Hépato-Biliaire, 94800, Villejuif, France.
- FHU Hepatinov, 94800, Villejuif, France.
- Physiopathogénèse et Traitement des Maladies du Foie, Inserm, Université Paris-Saclay, UMR-S 1193, Villejuif, France.
- Centre Hépato-Biliaire, Hôpital Paul Brousse, 12 Avenue Paul Vaillant Couturier, 94804, Villejuif, France.
| | - Julio Nunez
- Department of Surgery, Assistance Publique Hôpitaux de Paris, Paul-Brousse Hospital, Centre Hépato-Biliaire, 94800, Villejuif, France
| | - Alessandro Mazzotta
- Hepatobiliary and Digestive Surgery, Pontchaillou Hospital, Rennes 1 University, 35033, Rennes, France
| | - Luis Cano
- Nutrition Metabolism and Cancer, INRA, INSERM, Unit 991, CHU Rennes, Univ Rennes, Univ Bretagne Loire, Rennes, France
| | - Damien Bergeat
- Hepatobiliary and Digestive Surgery, Pontchaillou Hospital, Rennes 1 University, 35033, Rennes, France
| | - Laurent Sulpice
- Hepatobiliary and Digestive Surgery, Pontchaillou Hospital, Rennes 1 University, 35033, Rennes, France
| | - Heithem Jeddou
- Hepatobiliary and Digestive Surgery, Pontchaillou Hospital, Rennes 1 University, 35033, Rennes, France
| | - Ahmed Abdelrafee
- Department of Surgery, Assistance Publique Hôpitaux de Paris, Paul-Brousse Hospital, Centre Hépato-Biliaire, 94800, Villejuif, France
| | - Antonio Sa Cunha
- Department of Surgery, Assistance Publique Hôpitaux de Paris, Paul-Brousse Hospital, Centre Hépato-Biliaire, 94800, Villejuif, France
- FHU Hepatinov, 94800, Villejuif, France
- Physiopathogénèse et Traitement des Maladies du Foie, Inserm, Université Paris-Saclay, UMR-S 1193, Villejuif, France
| | - Daniel Cherqui
- Department of Surgery, Assistance Publique Hôpitaux de Paris, Paul-Brousse Hospital, Centre Hépato-Biliaire, 94800, Villejuif, France
- FHU Hepatinov, 94800, Villejuif, France
- Physiopathogénèse et Traitement des Maladies du Foie, Inserm, Université Paris-Saclay, UMR-S 1193, Villejuif, France
| | - René Adam
- Department of Surgery, Assistance Publique Hôpitaux de Paris, Paul-Brousse Hospital, Centre Hépato-Biliaire, 94800, Villejuif, France
- FHU Hepatinov, 94800, Villejuif, France
- INSERM, Unit 985, 94800, Villejuif, France
- Univ Paris-Sud, UMR-S 985, 94800, Villejuif, France
| | - Karim Boudjema
- Hepatobiliary and Digestive Surgery, Pontchaillou Hospital, Rennes 1 University, 35033, Rennes, France
| | - Eric Vibert
- Department of Surgery, Assistance Publique Hôpitaux de Paris, Paul-Brousse Hospital, Centre Hépato-Biliaire, 94800, Villejuif, France
- FHU Hepatinov, 94800, Villejuif, France
- Physiopathogénèse et Traitement des Maladies du Foie, Inserm, Université Paris-Saclay, UMR-S 1193, Villejuif, France
| |
Collapse
|
|
44
|
Bednarsch J, Czigany Z, Heij LR, Luedde T, van Dam R, Lang SA, Ulmer TF, Hornef MW, Neumann UP. Bacterial bile duct colonization in perihilar cholangiocarcinoma and its clinical significance. Sci Rep 2021; 11:2926. [PMID: 33536484 PMCID: PMC7858613 DOI: 10.1038/s41598-021-82378-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 01/15/2021] [Indexed: 02/07/2023] Open
Abstract
Abdominal infections including cholangitis represent a major problem in patients with perihilar cholangiocarcinoma (pCCA). Thus, we investigated bacterial colonization of the bile ducts and determined its impact on postoperative outcome focusing on abdominal infections. A cohort of 95 pCCA patients who underwent surgery between 2010 and 2019 with available intraoperative microbial bile cultures were analyzed regarding bile duct colonization and postoperative abdominal infection by group comparisons and logistic regressions. 84.2% (80/95) showed bacterial colonization of the bile ducts and 54.7% (52/95) developed postoperative abdominal infections. Enterococcus faecalis (38.8%, 31/80), Enterococcus faecium (32.5%, 26/80), Enterobacter cloacae (16.3%, 13/80) and Escherichia coli (11.3%, 9/80) were the most common bacteria colonizing the bile ducts and Enterococcus faecium (71.2%, 37/52), Enterococcus faecalis (30.8%, 16/52), Enterobacter cloacae (25.0%, 13/52) and Escherichia coli (19.2%, 10/52) the most common causes of postoperative abdominal infection. Further, reduced susceptibility to perioperative antibiotic prophylaxis (OR = 10.10, p = .007) was identified as independent predictor of postoperative abdominal infection. Bacterial colonization is common in pCCA patients and reduced susceptibility of the bacteria to the intraoperative antibiotic prophylaxis is an independent predictor of postoperative abdominal infections. Adapting antibiotic prophylaxis might therefore have the potential to improve surgical outcome pCCA patients.
Collapse
Affiliation(s)
- Jan Bednarsch
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Lara Rosaline Heij
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany.,Institute of Pathology, University Hospital RWTH Aachen, Aachen, Germany
| | - Tom Luedde
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Heinrich Heine University Duesseldorf, Düsseldorf, Germany
| | - Ronald van Dam
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany.,Department of Surgery, Maastricht University Medical Center (MUMC), Maastricht, The Netherlands
| | - Sven Arke Lang
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Tom Florian Ulmer
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany
| | | | - Ulf Peter Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany. .,Department of Surgery, Maastricht University Medical Center (MUMC), Maastricht, The Netherlands.
| |
Collapse
|
|
45
|
Langella S, Menonna F, Casella M, Russolillo N, Lo Tesoriere R, Alessandro F. Vascular Resection During Hepatectomy for Liver Malignancies. Results from a Tertiary Center using Autologous Peritoneal Patch for Venous Reconstruction. World J Surg 2021; 44:3100-3107. [PMID: 32418027 DOI: 10.1007/s00268-020-05564-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND To evaluate early outcomes of venous reconstruction with peritoneal patch (PP) during resection for hepatic malignancies. METHODS Since May 2015, PP was considered as the first option for venous reconstruction in the case of lateral resection. Between May 2015 and June 2019, 579 consecutive hepatectomies for malignancies were performed at our institution. Among 27 patients requiring venous resection, PP was used in 22, who were included in the present study. Data from a prospectively collected database were analysed. RESULTS Tumour types were ten colorectal metastases (CRLM), six intrahepatic cholangiocarcinomas, four hilar cholangiocarcinomas, one hepatocellular carcinoma and one gallbladder carcinoma. Hepatectomies were major in 50% of cases. Eleven patients had hepatic vein resections, eight portal vein and three inferior vena cava. Venous reconstruction enabled resection in 12 (54.5%) patients, otherwise non-resectable. Among CRLM, the venous reconstruction allowed avoidance of major resection in eight (80%) cases. Median operative time was 456 min (range 270-960). Blood loss was a median 300 cc (range 40-1500), and blood transfusions were required in three patients (13.6%). At pathological examination, venous infiltration was confirmed in 14 (63.6%) patients. No vascular complications related to the patch were recorded. Post-operative major (Dindo III/IV) complications were observed in two (9%) patients. One patient died because of liver failure without vascular thrombosis and one due to biliary fistula complicated by arterial bleeding. Overall, post-operative mortality was 9% (2/22). CONCLUSIONS Venous reconstruction with peritoneal patch during hepatectomy for malignancies can feasibly allow resection in otherwise unresectable patients and decrease the rate of major resection in colorectal liver metastases.
Collapse
Affiliation(s)
- Serena Langella
- Department of General and Oncological Surgery, Ospedale Mauriziano "Umberto I" Hospital, Largo Turati, 62, 10128, Turin, Italy.
| | - Francesca Menonna
- Department of General and Oncological Surgery, Ospedale Mauriziano "Umberto I" Hospital, Largo Turati, 62, 10128, Turin, Italy
| | - Michele Casella
- Department of General and Oncological Surgery, Ospedale Mauriziano "Umberto I" Hospital, Largo Turati, 62, 10128, Turin, Italy
| | - Nadia Russolillo
- Department of General and Oncological Surgery, Ospedale Mauriziano "Umberto I" Hospital, Largo Turati, 62, 10128, Turin, Italy
| | - Roberto Lo Tesoriere
- Department of General and Oncological Surgery, Ospedale Mauriziano "Umberto I" Hospital, Largo Turati, 62, 10128, Turin, Italy
| | - Ferrero Alessandro
- Department of General and Oncological Surgery, Ospedale Mauriziano "Umberto I" Hospital, Largo Turati, 62, 10128, Turin, Italy
| |
Collapse
|
|
46
|
Nooijen LE, Swijnenburg RJ, Klümpen HJ, Verheij J, Kazemier G, van Gulik TM, Erdmann JI. Surgical Therapy for Perihilar Cholangiocarcinoma: State of the Art. Visc Med 2021; 37:18-25. [PMID: 33708815 PMCID: PMC7923954 DOI: 10.1159/000514032] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/23/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Surgical therapy still offers the only chance of long-term survival for patients with perihilar cholangiocarcinoma (pCCA). The aim of this narrative review is to summarize the current standards and challenges in the surgical treatment of pCCA. SUMMARY After imaging and defining resectability, the first step towards optimal surgical treatment is optimizing biliary drainage and preventing cholangitis, followed by securing adequate future liver remnant volume and/or function. The main goal of resection for pCCA is achieving radical resection and ultimately long-term survival. In order to achieve radical resection, several points will be addressed (e.g., vascular resection and reconstruction, intraoperative frozen sections, right versus left hemihepatectomy, and the usefulness of preoperative [chemo]therapy). KEY MESSAGES In order to optimize long-term outcomes for patients with pCCA, collaboration between leading centers should be increased. In addition, this collaboration is necessary to design large prospective randomized controlled trials, as the incidence of pCCA is low and the number of resectable patients is even lower. Currently, most results are based on small retrospective cohort studies resulting in low evidence. In order to properly investigate how to improve long-term survival, we need to set up trials to confirm the results of small series suggesting the positive effect of preoperative chemotherapy and extended lymph node resection.
Collapse
Affiliation(s)
- Lynn E. Nooijen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Rutger-Jan Swijnenburg
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Heinz-Josef Klümpen
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joanne Verheij
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Geert Kazemier
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Thomas M. van Gulik
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joris I. Erdmann
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
|
47
|
Bednarsch J, Czigany Z, Lurje I, Amygdalos I, Strnad P, Halm P, Wiltberger G, Ulmer TF, Schulze-Hagen M, Bruners P, Neumann UP, Lurje G. Insufficient future liver remnant and preoperative cholangitis predict perioperative outcome in perihilar cholangiocarcinoma. HPB (Oxford) 2021; 23:99-108. [PMID: 32546423 DOI: 10.1016/j.hpb.2020.04.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 02/05/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Major liver resection has evolved as the mainstay of treatment for patients with perihilar cholangiocarcinoma (pCCA). Here we assessed the suitability of preoperative future liver remnant (FLR) measurement to predict perioperative complications, since surgical morbidity and mortality are high compared to other malignancies. METHODS Between 2011 and 2016, 91 patients with pCCA underwent surgery in curative intent at our institution. The associations of surgical complications with FLR and clinico-pathological characteristics were assessed using logistic regression analyses. Different methods of FLR assessment, the calculated-FLR (cFLR; ratio of FLR to total liver volume), standardized FLR (sFLR; ratio of FLR to liver volume estimated by body surface area) and FLR to bodyweight ratio (FLR/BW) were tested for validity. RESULTS Multivariable analysis identified preoperative cholangitis (Exp(B) = 0.236; p = 0.030) as the single significant predictor of postoperative mortality and cFLR (Exp(B) = 0.009, p = 0.004) as the single significant predictor of major postoperative morbidity (Clavien-Dindo ≥ 3b). Based on these findings we designed a futility criterion (cFLR<40% OR preoperative cholangitis) predicting in-house mortality. CONCLUSIONS In patients with pCCA, the preoperative FLR<40% as well as preoperative cholangitis are two risk factors to independently predict perioperative morbidity and mortality. The cFLR should be the preferred method of liver volumetry.
Collapse
Affiliation(s)
- Jan Bednarsch
- Georg Lurje, Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Zoltan Czigany
- Georg Lurje, Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Isabella Lurje
- Georg Lurje, Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany; Department of Hepatology and Gastroenterology, Campus Charité Mitte
- Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Germany
| | - Iakovos Amygdalos
- Georg Lurje, Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Pavel Strnad
- Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Paul Halm
- Georg Lurje, Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Georg Wiltberger
- Georg Lurje, Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Tom F Ulmer
- Georg Lurje, Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | | | - Philipp Bruners
- Department of Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Ulf P Neumann
- Georg Lurje, Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany; Department of Surgery, Maastricht University Medical Centre (MUMC), Maastricht, the Netherlands
| | - Georg Lurje
- Georg Lurje, Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany; Department of Surgery, Campus Charité Mitte
- Campus Virchow-Klinikum - Charité-Universitätsmedizin Berlin, Germany.
| |
Collapse
|
|
48
|
Multifocal pancreatobiliary malignancies: A diagnostic and therapeutic challenge. Radiol Case Rep 2020; 16:289-294. [PMID: 33299511 PMCID: PMC7708658 DOI: 10.1016/j.radcr.2020.11.018] [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: 10/31/2020] [Accepted: 11/11/2020] [Indexed: 02/07/2023] Open
Abstract
The synchronous presentation of multifocal pancreatobiliary tumors is a rare occurrence and can prove to be a significant diagnostic and therapeutic challenge. We describe the case of a 70-year-old female who presented with a 2-week history of jaundice, reduced appetite, and mild epigastric discomfort of insidious onset. Radiological evaluation with computed tomography and magnetic resonance imaging demonstrated features consistent with a hilar cholangiocarcinoma , also known as a Klatskin tumor, involving both the cystic duct and gallbladder neck. In addition to this, a pancreatic neoplasm with associated splenic vein occlusion and metastatic deposits in the liver and lung were identified. The patient was managed with percutaneous transhepatic external biliary drainage and stenting by interventional radiology. Cytology results from the brushings obtained from the aforementioned procedure were nondiagnostic. Core biopsies were performed of the pancreatic lesion; the histopathological results of which were in keeping with pancreatic ductal adenocarcinoma . The patient was scheduled for chemotherapy however unfortunately deteriorated clinically prior to commencement. This case highlights the diagnostic and management challenges of synchronous pancreatobiliary malignancies.
Collapse
|
|
49
|
Geers J, Jaekers J, Topal H, Aerts R, Vandoren C, Vanden Boer G, Topal B. Predictors of survival after surgery with curative intent for perihilar cholangiocarcinoma. World J Surg Oncol 2020; 18:286. [PMID: 33143698 PMCID: PMC7641817 DOI: 10.1186/s12957-020-02060-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 10/21/2020] [Indexed: 12/16/2022] Open
Abstract
Background Several clinicopathological predictors of survival after curative surgery for perihilar cholangiocarcinoma (pCCA) have been identified; however, conflicting reports remain. The aim was to analyse clinical and oncological outcomes after curative resection of pCCA and to determine prognostic factors. Methods Eighty-eight consecutive patients with pCCA underwent surgery with curative intent between 1998 and 2017. Survival curves were estimated using the Kaplan-Meier method and compared using the log-rank test. Twenty-one prognostic factors were evaluated using multivariate Cox regression models. Results Postoperative complications were observed in 73 (83%) patients of which 41 (47%) were severe complications (therapy-oriented severity grading system (TOSGS) grade > 2), including a 90-day mortality of 9% (n = 8). Overall survival (OS) and disease-free survival (DFS) rates at 5 and 10 years after surgery were 33% and 19%, and 37% and 30%, respectively. Independent predictors of OS were locoregional lymph node metastasis (LNM) (risk ratio (RR) 2.12, confidence interval (CI) 1.19–3.81, p = 0.011), patient American Society of Anesthesiologists (ASA) physical status classification system > 2 (RR 2.10, CI 1.03–4.26, p = 0.043), and depth of tumour penetration (pT) > 2 (RR 2.58, CI 1.03–6.30, p = 0.043). The presence of locoregional LNM (RR 2.95, CI 1.51–5.90, p = 0.002) and caudate lobe resection (RR 2.19, CI 1.01–5.14, p = 0.048) were found as independent predictors of DFS. Conclusions Curative surgery for pCCA carries high risks with poor long-term survival. Locoregional LNM was the only predictor for both OS and DFS.
Collapse
Affiliation(s)
- Joachim Geers
- Department of Visceral Surgery, University Hospitals KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Joris Jaekers
- Department of Visceral Surgery, University Hospitals KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Halit Topal
- Department of Visceral Surgery, University Hospitals KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Raymond Aerts
- Department of Visceral Surgery, University Hospitals KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Cindy Vandoren
- Management Information & Registration, University Hospitals KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Guy Vanden Boer
- Management Information & Registration, University Hospitals KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Baki Topal
- Department of Visceral Surgery, University Hospitals KU Leuven, Herestraat 49, 3000, Leuven, Belgium.
| |
Collapse
|
|
50
|
Sucher R, Scheuermann U, Seehofer D. Total Laparoscopic Resection of Hilar Cholangiocarcinoma Type 3b: Applying a Parachute Technique for Hepaticojejunostomy. Ann Surg Oncol 2020; 28:2030-2034. [PMID: 33000370 PMCID: PMC7940288 DOI: 10.1245/s10434-020-09175-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 09/08/2020] [Indexed: 12/15/2022]
Abstract
Background Laparoscopic liver resection for perihilar cholangiocarcinoma (pCCA) is still in its infancy. The biliary-enteric reconstruction represents one of the most delicate parts of this minimally invasive procedure. Methods In this study, a 78-year old woman with perihilar cholangiocarcinoma (pCCA) type 3b underwent a hepaticojejunostomy performed by a parachute technique. Results The operation, performed totally by minimally invasive resections, was completed in 386 min, with a blood loss of less than 400 ml and no transfusion requirements. Two intraluminal stents were placed during the hepaticojenunostomy for splinting of the biliary-enteric anastomosis. The patient required prolonged antibiotic treatment for postoperative cholangitis and finally was discharged on postoperative day 15. The histopathologic grading displayed a G 2–3 adenocarcinoma, pT3 pN0, M0, L1, V1, pN1, UICC IIIc R0, and the patient was referred to adjuvant chemotherapy. Conclusion Resections of pCCAs, performed totally by minimally invasive techniques, may be feasible and safe for a selected group of patients. With this approach, a running-suture hepaticojejunostomy using the parachute technique represents a worthwhile strategy for biliary-enteric reconstruction. Electronic supplementary material The online version of this article (10.1245/s10434-020-09175-1) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Robert Sucher
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Clinic Leipzig, Leipzig, Germany.
| | - Uwe Scheuermann
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Clinic Leipzig, Leipzig, Germany
| | - Daniel Seehofer
- Department of Visceral, Transplant, Thoracic, and Vascular Surgery, University Clinic Leipzig, Leipzig, Germany
| |
Collapse
|