Is Major Hepatectomy with Portal Vein Resection or Pancreatoduodenectomy for Advanced Gallbladder Cancer Justified?

Abstract

Introduction: The clinical impact of major hepatectomy with portal vein resection or pancreatoduodenectomy (PD) for advanced gallbladder cancer remains unclear. Methods: A total of 96 patients underwent resection for Stage II, III, or IV gallbladder cancer between 2003 and 2012. Of these, 29 patients who underwent major hepatectomy (major Hx group; resecting two or more sections) were enrolled in this study. During the same period, resection was not undertaken after laparotomy in 15 patients (unresectable group) because they had unsuspected distant metastases. Of these, 12 patients underwent non-surgical chemotherapy treatments. We analyzed whether major Hx with portal vein resection (PVR) or PD are justified for patients with advanced gallbladder cancer. Results: In the major Hx group, nine patients underwent PVR and nine patients underwent major hepatopancreatoduodenectomy (HPD). Mortality was zero in the major Hx group. The median survival time (MST) and the 5-year survival rate (5yrOS) in the major Hx group were 17.7 months and 27.8%, respectively, compared to 11.4 months and 0.0%, respectively, in the unresectable group. The patients in the major Hx group had a significantly better prognosis than those in the unresectable group (p=0.003, Fig. 1); there were five long-term survivors of more than five years in the major Hx group. In the subgroup analysis of the major Hx group, the OS in the patients who underwent PVR (n=9, MST 16.3 months, 5yrOS 33.3%, p=0.872, Fig. 2a) or major HPD (n=9, MST 29.8 months, 5yrOS 41.7%, p=0.440, Fig. 2b) was comparable with that seen in the subjects who did not undergo PVR (n=20) or major HPD (n=20). The multivariate analysis revealed that liver metastasis (n=3, p=0.038) and hepatic arterial invasion (n=6, p=0.017) were independently associated with the poor survival. In the comparison with the unresectable group, the OS in the patients with liver metastasis (p=0.572) and hepatic arterial invasion (p=0.776, Fig. 2c) were comparable with those seen in the unresectable group. However, the OS in the patients with lymph node metastasis (n=20, p=0.062, Fig. 2d), PVR (p=0.054), or major HPD (p=0.011) was better than those seen in the unresectable group.Figure 1Figure 2Table 1: Results of univariate and multivariate analyses regarding the prognostic factors associated with overall survival in the 29 patients treated with major hepatectomy for gallbladder cancerConclusion: Even in patients with lymph node metastasis and/or a need for PVR or major HPD, the surgeon can consider aggressive surgery with lymphadenectomy and combined PVR or combined PD, especially in selected patients without liver metastasis or hepatic arterial invasion.Figure 3