Factors influencing postoperative morbidity, mortality, and survival after resection for hilar cholangiocarcinoma.

UNLABELLED OBJECTIVE; Morbidity and mortality involved in the resection of hilar cholangiocarcinoma were reviewed retrospectively. The clinicopathologic and laboratory parameters that might influence the patient's survival also were re-evaluated. SUMMARY BACKGROUND DATA Although much progress has been made in the diagnosis and management of hilar cholangiocarcinoma, long-term outlook for most patients remains poor. Surgical resection is usually prohibited because of its local invasiveness, and most patients can only be managed by palliative drainage. Recently, many surgeons have adopted a more aggressive resection with varying degrees of success. Several prognostic factors in bile duct carcinoma have been proposed; however, no reports have specifically focused on resected hilar cholangiocarcinoma and its prognostic survival factors using multivariate analysis. METHODS The clinical records and pathologic slides of 49 cases with resected hilar cholangiocarcinoma were reviewed retrospectively. Twenty clinical and laboratory parameters were evaluated for their correlation with postoperative morbidity and mortality, whereas 31 variables were evaluated for their significance with postoperative survival. Variables showing statistical significance in the first univariate analysis were included in the following multivariate analysis using stepwise logistic regression test for factors affecting morbidity and mortality and Cox stepwise proportional hazard model for factors influencing survival. RESULTS There were 5 in-hospital deaths, and the cumulative 5-year survival rate in 44 patients who survived was 14.9%, with a median survival of 14.0 months. Multivariate analysis disclosed that co-existent hepatolithiasis and lower serum asparate aminotransferase levels (<90 U/L) had a significant low incidence of postoperative morbidity, whereas a serum albumin of less than 3 g/dL was the only significant factor affecting mortality. Regarding survival, univariate analysis identified eight significant factors: 1) total bilirubin > or = 10 mg/dL, 2) curative resection, 3) histologic type, 4) perineural invasion, 5) liver invasion, 6) depth of cancer invasion, 7) positive proximal resected margin, and 8) positive surgical margin. However, multivariate analysis disclosed total bilirubin > or = 10 mg/dL, curative resection, and histologic type as the three most significant independent variables. CONCLUSIONS Surgical resection provides the best survival for hilar cholangiocarcinoma. An adequate nutritional support to increase serum albumin over 3 g/dL is the most important factor to decrease postoperative mortality. Moreover, preoperative biliary drainage to decrease jaundice and a curative resection with adequate surgical margin are recommended if longer survival is anticipated. Patients with well-differentiated adenocarcinoma seem to survive longer compared to those with moderately or poorly differentiated tumors.

[1]  Yuan‐Jen Wang,et al.  Clinical experience in 126 patients with tissue‐proved proximal cholangiocarcinoma , 1994, Journal of gastroenterology and hepatology.

[2]  S. Kondo,et al.  Clinicopathologic studies on perineural invasion of bile duct carcinoma. , 1992, Annals of surgery.

[3]  S. Kondo,et al.  Combined portal vein and liver resection for carcinoma of the biliary tract , 1991, The British journal of surgery.

[4]  M. Makuuchi,et al.  Preoperative portal embolization to increase safety of major hepatectomy for hilar bile duct carcinoma: a preliminary report. , 1990, Surgery.

[5]  M. Sapozink,et al.  Definitive radiation therapy in bile duct carcinoma. , 1988, International journal of radiation oncology, biology, physics.

[6]  O. Ishikawa,et al.  Practical Usefulness of Lymphatic and Connective Tissue Clearance for the Carcinoma of the Pancreas Head , 1988, Annals of surgery.

[7]  Nagorney Dm,et al.  Carcinoma of the gallbladder and extrahepatic bile ducts. , 1988 .

[8]  T. T. White.  Skeletization resection and central hepatic resection in the treatment of bile duct cancer , 1988, World journal of surgery.

[9]  Adkins Rb,et al.  An aggressive surgical approach to bile duct cancer. , 1986 .

[10]  H. Pitt,et al.  Does Preoperative Percutaneous Biliary Drainage Reduce Operative Risk or Increase Hospital Cost? , 1985, Annals of surgery.

[11]  L. Blumgart,et al.  Clinicopathological aspects of high bile duct cancer. Experience with resection and bypass surgical treatments. , 1984, Annals of surgery.

[12]  D J Allison,et al.  Pre‐operative percutaneous transhepatic biliary drainage: The results of a controlled trial , 1984, The British journal of surgery.

[13]  S. Duffy,et al.  Factors affecting morbidity and mortality after surgery for obstructive jaundice: a review of 373 patients. , 1983, Gut.

[14]  S. Blamey,et al.  Prediction of risk in biliary surgery , 1983, The British journal of surgery.

[15]  I. Marks,et al.  PREOPERATIVE EXTERNAL BILIARY DRAINAGE IN OBSTRUCTIVE JAUNDICE A Prospective Controlled Clinical Trial , 1982, The Lancet.

[16]  W. Longmire,et al.  Prognostic Factors in Bile Duct Carcinoma: Analysis of 96 Cases , 1981, Annals of surgery.

[17]  P. Brissot,et al.  Carcinoma of the Hepatic Hilus Surgical Management and the Case for Resection , 1979, Annals of surgery.

[18]  K. Okuda,et al.  Percutaneous transhepatic drainage of the biliary tract: Technique and results in 104 cases , 1978 .

[19]  B. Gray,et al.  Considerations that lower pancreatoduodenectomy mortality. , 1977, American journal of surgery.

[20]  M. Kojiro,et al.  Clinical aspects of intrahepatic bile duct carcinoma including hilar carcinoma. A study of 57 autopsy‐proven cases , 1977, Cancer.

[21]  R. Praderi.  Twelve Years' Experience with Transhepatic lntubation , 1974, Annals of surgery.

[22]  J. Louw,et al.  Prolonged palliation in carcinoma of the man hepatic duct junction. , 1972, Surgery.

[23]  R. Sullivan,et al.  Hepaticojejunostomy. Modified longmire operation for bile duct carcinoma. , 1967, American journal of surgery.

[24]  G. Klatskin.  ADENOCARCINOMA OF THE HEPATIC DUCT AT ITS BIFURCATION WITHIN THE PORTA HEPATIS. AN UNUSUAL TUMOR WITH DISTINCTIVE CLINICAL AND PATHOLOGICAL FEATURES. , 1965, The American journal of medicine.

[25]  G. Klatskin.  CONGENITAL HEMOLYTIC JAUNDICE CORRECTED BY SPLENECTOMY FOLLOWED TWENTY-SIX YEARS LATER BY BLEEDING TENDENCY, HEPATOMEGALY AND SUDDEN DEATH. , 1965, The American journal of medicine.

[26]  W. Russell,et al.  ACTION OF PHENOL ON SPINAL NERVE-ROOTS. , 1964, Lancet.

[27]  J. Myburgh.  Resection and bypass for malignant obstruction of the bile duct , 1995, World journal of surgery.

[28]  H. Bismuth,et al.  Management strategies in resection for hilar cholangiocarcinoma. , 1992, Annals of surgery.

[29]  J. Cameron,et al.  Management of proximal cholangiocarcinomas by surgical resection and radiotherapy. , 1990, American journal of surgery.

[30]  H. Pitt,et al.  Factors affecting mortality in biliary tract surgery. , 1981, American journal of surgery.

[31]  S. Bengmark,et al.  Evaluation of aggressive surgery for carcinoma of the extrahepatic bile ducts. , 1980, Annals of surgery.

[32]  K. Kelly,et al.  Surgical treatment of adenocarcinoma. Location: junction of the right, left, and common hepatic biliary ducts. , 1979, Archives of surgery.