Additional Intrapancreatic Bile Duct Resection and Additional Pancreaticoduodenecotmy for Positive Distal Ductal Margin of Hilar Cholangiocarcinoma

Abstract

Introduction: The feasibility and effectiveness of intrapancreatic bile duct resection (IPBR) and additional pancreaticoduodenectomy (aPD) for initial cancer positive distal duct margin (DM) in perihilar cholangiocarcinoma cases remain to be elucidated. The aim of this study was to clarify the feasibility and efficacy of both operative procedures. Method: All patients who underwent major hepatectomy and extrahepatic bile duct resection for perihilar cholangiocarcinoma between 2000 and 2020 were analyzed. IPBR for cancer positive DMs were indicated for cases with cancer-negative proximal margin and no extra-bile duct invasion. Results: A total 364 patients were enrolled. Additional resection was performed in 69 of 89 cancer positive DMs, resulting in 53 negative DMs (77%). Procedures of additional resection were 59 IPBR and 10 aPD. A multivariate analysis demonstrated that high preoperative serum carbohydrate antigen 19-9 level, combined hepatic artery resection, nodal involvement, distant metastasis, severe perineural invasion and R 1 resection were independent worse prognostic factors. DM was not prognostic factors independently. Only three cases developed initial recurrence at intrapancreatic bile duct in all positive DM cases (one in invasive cancer positive DM case, 1 year after resection and two with cancer-in-situ (CIS) positive DM cases, 4 and 6 year after resection). Overall survival of patients with cancer positive initial DM and cancer negative or CIS final DM treated by IPBR (n=56) were statistically compared with that of the patients treated by aPD (P=0.24). Conclusions: IPBR was feasible and effective procedure for the selected patients of cancer positive DMs of wide spread perihilar cholangiocarcinoma.