Outcomes in Hilar Cholangiocarcinoma Management through a Clinical Pathway Implementation: A 30-year Single Centre Experience

Abstract

Introduction: Multidisciplinary team assessment and clinical pathways improve the outcomes of cancer treatments. Perihilar-cholangiocarcinoma is a rare disease, and surgical resection remains the only possibility of curative treatment. The present study aimed to investigate patient outcomes after the introduction of an institutional Perihilar cholangiocarcinoma clinical pathway. Methods: All patients with a diagnosis of Perihilar-cholangiocarcinoma, between 1988 and 2018 were identified from a prospectively collected database. Outcomes from a historical control group of 508 (83%) patients were compared with patients after the implementation of the Perihilar-cholangiocarcinoma clinical pathway (n=107; 17%). Results: Median Charlson Comorbidities Index (CCI) was 5 (IQ 4-6) in the Perihilar-cholangiocarcinoma clinical pathway and 4 (IQ 3-5) before the Clinical pathway (p< 0.0001). The overall number of patient defined as localized without vascular involvement, vascular involvement, and with metastatic diseases were 28% (n=28), 49% (n=50), and 24% (n=24) within the Perihilar-cholangiocarcinoma clinical pathway and 42% (n=101), 40% (n=94), and 17% (n=41) before introduction of the Clinical Pathway (p=0.02). The non-surgical candidates were 369 (73%) and 60 (58%), and the exploratory laparotomies without resections were 49 (10%) and 15 (14%), respectively (p=0.01). One-year survival was 61% vs. 67% (HR: 2.664 CI: 1.056 to 6.639, p=0.032) in the no clinical pathway and in the Perihilar-cholangiocarcinoma clinical pathway. Conclusion: The introduction of the Perihilar-cholangiocarcinoma clinical pathway significantly increased the resection rate trough a significant number of patients with vascular involvement deemed resectable within the pathway. Such results are consistent with the standard approach of other high volume international centres.