Surgery For Cholangiocarcinoma Research Articles

Metastatic Endophthalmitis Secondary to a Bacterial Liver Abscess before Surgery for Cholangiocarcinoma—A Case Report—

Metastatic Endophthalmitis Secondary to a Bacterial Liver Abscess before Surgery for Cholangiocarcinoma—A Case Report—

<p>Preoperative Bilirubin-Adjusted Carbohydrate Antigen 19-9 as a Prognostic Factor for Extrahepatic Cholangiocarcinoma Patients at a Single Center</p>

PurposeThe aims of our study were to investigate the prognostic impact of the rate of preoperative serum carbohydrate antigen 19-9/bilirubin (CA19-9/BR) on patients with extrahepatic bile duct cancer.Patients and MethodsWe collected clinical data from 89 patients who underwent surgery for extrahepatic cholangiocarcinoma (ECC) at Peking Union Medical College Hospital between January 2012 and December 2017. The Kaplan–Meier analysis for univariate analysis and the Cox proportional hazards models for multivariate analysis were used to determine possible independent prognostic factors.ResultsCA19-9/BR was classified as elevated compared with normal based on the upper serum normal values of CA19-9 (37 U/mL) and bilirubin (1.5 mg/dL), which gives a cut-off at 25 U/mL/mg/dL. Univariate analysis showed that the overall survival of patients with a high CA19-9/BR ratio was significantly worse compared with patients with a low CA19-9/BR ratio (Hazard Ratio [HR] 2.149; 95% Confidence Interval [95% CI] 1.027–4.495; P=0.042). Multivariate analysis revealed that a high CA19-9/BR ratio (HR 3.250; 95% CI 1.165–9.067; P=0.024), low differentiation (HR 3.551; 95% CI 1.231–10.244; P=0.019), and positive margin (HR 2.555; 95% CI 1.111–5.875; P=0.027) remained independent prognostic factors after adjusting for age at diagnosis, maximal diameters, and other possible factors.ConclusionThe preoperative CA19-9/BR ratio is a good prognostic factor in predicting survival in ECC patients and closer follow-up is recommended in patients with a higher CA19-9/BR ratio before surgery.

A case of metachronous intrahepatic cholangiocarcinoma after curative surgery for extrahepatic cholangiocarcinoma

A case of metachronous intrahepatic cholangiocarcinoma after curative surgery for extrahepatic cholangiocarcinoma

Outcomes of surgical resection in type iii and type IV peri-hilar cholangiocarcinoma

Introduction: Peri-hilar cholangiocarcinoma (PH-CCA) is a rare tumour of the liver hilus. The majority of patients are not candidates for surgery either because of co-morbidity or advanced cancer stage. This is a single-centre case cohort series of prospectively collected data with an emphasis on criteria for resectability, type of surgery and outcome. Methods: During the 10 year period January 2009 to January 2019, 384 patients underwent hepatectomy by an individual HPB surgeon (AKS) in a regional liver surgery service. 20 underwent hepatectomy for type III or type IV peri-hilar cholangiocarcinoma and constitute the study population of this report. Patients undergoing surgery for intra-hepatic cholangiocarcinoma are excluded. Pre-operative preparation included percutaneous trans-hepatic drainage of the future liver remnant followed by cardiopulmonary exercise testing. Biliary involvement was assessed by pre-operative contrast-enhanced magnetic resonance scan. No patients underwent laparoscopy. There was no policy of neoadjuvant chemo- or radiotherapy. Hepatic resection was with CUSA (Valleylab, Boulder CO, USA). Resection included segment I and reconstruction of biliary drainage was by Roux hepaticojejunostomy. The study was listed as an audit. Results: 7 (35%) were IIIa, 7 (35%) were IIIb and 6 were type IV. During the period of this study no patients underwent laparotomy without resection. The median (range) operating time was 600 (240-720) minutes) with a median transection time of 100 (60- 150) minutes. 1 (5%) required early re-operation for bleed. There were no post-operative deaths. Histology confirmed an R0 resection margin in 15 (75%). Conclusion: This is a highly selected series and care must be exercised when extrapolating from these Results. However, the data show that liver resection in the hands of an experienced team is a feasible option in carefully assessed patients with type III and type IV PH-CCA.

Preoperative risk score for prediction of long-term outcomes after hepatectomy for intrahepatic cholangiocarcinoma: Report of a collaborative, international-based, external validation study

PurposeA preoperative risk score (PRS) to predict outcome of patients with intrahepatic cholangiocarcinoma treated by liver surgery could be clinically relevant.To assess accuracy for broadly adoption, external validation of predictive models on independent datasets is crucial.The objective of this study was to externally validate the score for prediction of long-term outcomes after liver surgery for intrahepatic cholangiocarcinoma proposed by Sasaki et al. and based on preoperative albumin, neutrophil-to-lymphocytes-ratio, CA19-9 and tumor size. MethodsPatients treated by liver surgery for intrahepatic cholangiocarcinoma at 11 international HPB centers from 2001 to 2018 were included in the external validation cohort. Harrell's c-index and Hosmer-Lemeshow analyses were used to test PRS discrimination and calibration. Kaplan–Meier curve for risk groups as described in the original study were displayed. ResultsA total of 355 patients with 174 deaths during the follow-up period (median = 41.7 months, IQR 32.8–50.6) were included. The median PRS value was 14.7 (IQR 10.7–20.6), with normal distribution across the cohort. A Cox regression on PRS covariates found coefficients similar to those of the derivation cohort, except for tumor size. Measures of discrimination estimated by Harrell's c-index was 0.61(95%CI:0.56–0.67) and Hosmer-Lemeshow p = 0.175. The Kaplan-Meyer estimation showed reasonable discrimination across risk groups, with 5years survival rate ranging from 20.1% to 0%. ConclusionIn this external validation cohort, the PRS had mild discrimination and poor calibration performance, similarly to the original publication. Nevertheless, its ability to identify different classes of risk is clinically useful, for a better tailoring of a therapeutic strategy.

Laparoscopic resection for Bismuth type III and IV hilar cholangiocarcinoma: How to improve the radicality without direct palpation

Open surgery for hilar cholangiocarcinoma (HCCA) has already been widely reported and analyzed. However, the laparoscopic technique for treating HCCA remains controversial because of the lack of radicality and poor assessment of the resectability of hilar structures without direct palpation. The aim of this study was to provide detailed surgical procedures and photographs of this technically demanding operation, describe our experience in assessing resectability before and during surgery, and confirm the radicality of laparoscopic resection of Bismuth type III and IV HCCA. From November 2016 to November 2018, nine patients received laparoscopic resection of Bismuth type III or IV HCCA in our department. Laparoscopic right hepatectomy was performed in four patients, and laparoscopic left hepatectomy was performed in five patients. Negative margins were achieved in all patients. Complications were found in two(22.22%) patients, with bile leakage and hepatic insufficiency each in one patient. The patient developing hepatic insufficiency had persistent and ongoing liver failure and finally expired. The radicality of laparoscopic resection for Bismuth type III and IV HCCA can be technically improved through extended lymphadenectomy, visual assessment of hilar structures, and frozen section techniques.

Carbon-ion radiotherapy for cholangiocarcinoma: a multi-institutional study by and the Japan carbon-ion radiation oncology study group (J-CROS).

To evaluate the safety and efficacy of carbon-ion radiotherapy (CIRT) for cholangiocarcinoma via a multicenter retrospective study. Clinical data were collected from patients with cholangiocarcinoma who had received CIRT at one of four treating institutions in Japan. Of 56 eligible patients, none received surgery for cholangiocarcinoma before or after CIRT. The primary endpoint was overall survival (OS). Based on the tumor site, the 56 cases were categorized as intrahepatic cholangiocarcinoma (IHC) (n=27) or perihilar cholangiocarcinoma (PHC) (n=29). In all patients, the median tumor size was 37 (range, 15‒110) mm, and the most commonly prescribed dose was 76 Gy (relative biological effectiveness) in 20 fractions. The median survival was 14.8 (range, 2.1-129.2) months, and the 1- and 2-year OS rates were 69.7% and 40.9%, respectively. The median survival times of the patients with IHC and those with PHC were 23.8 and 12.6 months, respectively. Both univariate and multivariate analyses revealed that cholangitis pre-CIRT and Child‒Pugh class B were significant prognostic factors for an unfavorable OS. Of four patients who died of liver failure, one with IHC was suspected to have radiation-induced liver disease because of newly developed ascites, and died at 4.3 months post-CIRT. Grade 3 CIRT-related bile duct stenosis was observed in one IHC case. No other CIRT-related severe adverse events, including gastrointestinal events, were observed. These results suggest that CIRT yields relatively favorable treatment outcomes, especially for patients with IHC, and acceptable toxicities were observed in patients with cholangiocarcinoma who did not receive surgery.

Perihilar Cholangiocarcinoma

Hilar cholangiocarcinomas (HCs) are a diverse group of aggressive tumors often diagnosed late in disease due to their typically longitudinal spread along the biliary system. Only approximately one-third of HCs are the candidates for resection, which offers the only chance for cure. However, even following resection, recurrence is common, and 5-year survival rates after surgery remain dismal at 20 to 42%. A thorough preoperative work-up and risk stratification for major surgery are critical to treatment success and maximizing the likelihood of an R0 resection. Due to the relatively few large phase III randomized controlled trials for HC, data are lacking on the optimal adjuvant treatment. Recent results of the BILCAP trial are promising for improved survival after surgery with adjuvant therapy, particularly capecitabine. When resection is not an option, prognosis is poor with median survival of less than 12 months. However, there are multiple chemotherapy-based treatment options that have demonstrated prolonging survival, with combined gemcitabine and cisplatin as first-line therapy. Liver transplantation should be considered on protocol for unresectable HC in the absence of metastatic disease. Palliative options, such as photodynamic therapy or radiation, may also be considered in advanced disease. This review contains 2 figures, 5 tables, and 41 references. Key Words: adjuvant therapy in cholangiocarcinoma, hilar cholangiocarcinoma, Klatskin tumor, metastatic cholangiocarcinoma, perihilar cholangiocarcinoma, portal dissection, surgery for hilar cholangiocarcinoma, outcomes in hilar cholangiocarcinoma

Perihilar Cholangiocarcinoma

Hilar cholangiocarcinomas (HCs) are a diverse group of aggressive tumors often diagnosed late in disease due to their typically longitudinal spread along the biliary system. Only approximately one-third of HCs are the candidates for resection, which offers the only chance for cure. However, even following resection, recurrence is common, and 5-year survival rates after surgery remain dismal at 20 to 42%. A thorough preoperative work-up and risk stratification for major surgery are critical to treatment success and maximizing the likelihood of an R0 resection. Due to the relatively few large phase III randomized controlled trials for HC, data are lacking on the optimal adjuvant treatment. Recent results of the BILCAP trial are promising for improved survival after surgery with adjuvant therapy, particularly capecitabine. When resection is not an option, prognosis is poor with median survival of less than 12 months. However, there are multiple chemotherapy-based treatment options that have demonstrated prolonging survival, with combined gemcitabine and cisplatin as first-line therapy. Liver transplantation should be considered on protocol for unresectable HC in the absence of metastatic disease. Palliative options, such as photodynamic therapy or radiation, may also be considered in advanced disease. This review contains 2 figures, 5 tables, and 41 references. Key Words: adjuvant therapy in cholangiocarcinoma, hilar cholangiocarcinoma, Klatskin tumor, metastatic cholangiocarcinoma, perihilar cholangiocarcinoma, portal dissection, surgery for hilar cholangiocarcinoma, outcomes in hilar cholangiocarcinoma

Trends in surgery and disparities in receipt of surgery for intrahepatic cholangiocarcinoma in the US: 2005-2014.

Intrahepatic cholangiocarcinoma (IHC) is a malignancy with an increasing incidence. Surgery is the only treatment modality associated with long term survival. The objective of this study is to utilize a nationwide representative database to quantify the trends in incidence, and surgery for IHC in the United States from 2004-2014, as well as identify any disparities in the receipt of surgery. All patients admitted with a diagnosis of IHC between 2005 and 2014 were identified from the Nationwide Inpatient Sample (NIS) database. Trends in the number of IHC admissions and surgery procedures as well as outcomes were examined, and a multivariate analysis was used to determine the effects of demographic and clinical co-variables on resection rates. An estimated total of 104,045 IHC related admissions occurred between 2005 and 2014. The hospitalization rate for IHC increased by nearly 2-fold in 2014 [38.9 per 100,000 (95% CI, 35.7-42.2)] from 18.1 per 100,000 (95% CI, 15.8-20.3) in 2005. Liver resections increased 248% (P<0.01) with an increasing majority being performed at teaching hospitals and 56% being minor resections. There was an increase in estimated hospital charges from $87,124 to $148,613 (P<0.001) and decrease in LOS from 12 days to 10 days (P<0.01). Inpatient mortality for IHC decreased significantly from 11% to 8.4% (P=0.004), from year 2005 to 2014 respectively. Age >80 years (OR =0.45; 95% CI, 0.33-0.60), Black race (OR =0.50; 95% CI, 0.39-063), Hispanic race (OR =0.59; 95% CI, 0.45-0.79), Medicaid insurance (OR =0.58; 95% CI, 0.42-0.79) and Elixhauser comorbidity score >3 (OR =0.58; 95% CI, 0.47-0.73) were associated with decreased rates of resection. Overall hospitalization and volume of surgery for IHC has increased dramatically over the past decade. There has been an increase in cost, decrease in LOS and inpatient mortality during the period. Socioeconomic and racial disparities were observed in the receipt of surgery for IHC. Additional work is needed to understand the complex interplay between socioeconomic status and race in in the treatment of IHC.

Surgical and histological boundary of the hepatic hilar plate system: basic study relevant to surgery for hilar cholangiocarcinoma regarding the "true" proximal ductal margin.

We sought to expand the clinico-anatomical limit of the proximal ductal margin (Limit-PDM) for resectability of hilar cholangiocarcinoma (HCCA). The practical boundary of the hilar plate (PBHP) was defined as the location where the bile duct (BD) could not be isolated by dissection. The distance between PBHP and two well-known clinical landmarks of Limit-PDM, the right edge of the bifurcation of the anterior and posterior branch of the right portal vein (Posterior-Landmark) and the left edge of the umbilical portion of the portal vein (Left-Landmark), and histological features around the PBHP were assessed using 55 adult cadaver livers. BD was almost always isolatable beyond the traditional clinical landmarks. The median distance was 6.9 mm (interquartile range [IQR] 6.0-8.3 mm) between the PBHP and the Posterior-Landmark, and 8.9 mm (IQR 6.7-10.2 mm) between the PBHP and the Left-Landmark. Histologically, the sheath surrounding the portal triad was loose, thick with few elastic fibers and small arteries near the hepatic hilum. Near the PBHP, the sheath was dense, thin, and abundant with elastic fibers and small arteries. Limit-PDM is more peripheral than the traditional clinical landmark-based margin and histological transition near the PBHP was revealed.

Laparoscopic radical resection of hilar cholangiocarcinoma: a report of 32 patients

Objective To analyze the clinical outcomes and surgical procedures of 32 patients who underwent laparoscopic radical resection of hilar cholangiocarcinoma. Methods From January 2013 to July 2018, 32 patients who were diagnosed to have hilar cholangiocarcinoma underwent total laparoscopic treatment in Second Hospital of Hebei Medical University. The clinical data of these patients were recorded, including the general data, Bismuth types, AJCC types, postoperative complications, pathological findings, and follow-up results. Results This study included 20 males and 12 females with a mean age of 60.9±8.8 years and a body mass index of 22.6±3.2 kg/m2. According to the preoperative imaging studies, the Bismuth types Ⅰ, Ⅱ, Ⅲa, Ⅲb, and Ⅳ were found in 12, 2, 3, 4 and 11 patients, respectively. Laparoscopic radical resection of hilar cholangiocarcinoma and bilioenteric anastomosis was performed in 12 patients, with radical resection and external bile drainage in 6 patients, extended hemihepatectomy with caudate lobectomy in 6 patients and concomitant portal vein resection in 2 patients. The mean operative time was 365.6±121.9 min and the median intraoperative blood loss was 300 (75, 400) ml. Intraoperative red cell and plasma transfusion were 0-15 U and 400(0, 625)ml, respectively. According to the Clavien-Dindo complication classification system, 5 of 32 (15.6%) patients developed type Ⅱ morbidity. The postoperative pathological findings revealed bile duct adenocarcinoma in 30 patients and mucinous adenocarcinoma in 2 patients. The median size of cancer was 3.0 (1.0, 3.5) cm. According to the 8th AJCC staging system, stage Ⅰ, Ⅱ, Ⅲ, and Ⅳ were found in 6, 13, 11, and 2 patients, respectively. A negative resection margin was achieved in 24 of 32 patients (75%). Up to August 6, 30 of 32 patients (93.8%) were followed up and the overall 1-, 2-, and 3-year survival rates for the patients who underwent laparoscopic radical resection for hilar cholangiocarcinoma were 80.0%, 53.0%, and 53.3%. The median survival time was 21.8 months. Conclusion Total laparoscopic surgery for hilar cholangiocarcinoma was safe and feasible if performed by an experienced surgeon after accurate preoperative evaluation. Key words: Bile duct neoplasms; Surgical procedures, minimally invasive; Laparoscopy; Drainage; Hilar cholangiocarcinoma

Effectiveness of surgery for recurrent cholangiocarcinoma: A single center experience and brief literature review

BackgroundIn this study, we reviewed our experiences and previous studies on surgery for recurrent cholangiocarcinoma (CCA). MethodsWe analyzed outcomes of 117 patients with recurrent CCA between 2000 and 2015. Twenty-one patients (17.9%) underwent surgical resection for recurrence, and the remaining 96 patients (82.1%) did not undergo resection. We evaluated patients’ clinicopathological features and prognoses between the two groups. ResultsPatients who underwent surgery were significantly associated with better overall survival after recurrence (HR = 0.22, P < 0.0001). In patients with recurrent CCA, surgery for recurrence was an independent better prognostic factor after recurrence (HR = 0.27, P = 0.0002), and in patients who underwent surgery for recurrent CCA, the presence of lymph node metastasis of primary cancer was an independent worse prognostic factor (HR = 9.45, P = 0.04). ConclusionsSurgery for recurrent CCA may provide good survival impact in selected patients. Patients with lymph node metastasis of primary CCA should not undergo surgery for recurrent CCA.

Racial/ethnic disparities in the use of high-volume centers for hepatobiliary and pancreatic cancer surgery.

457 Background: The impact of hospital volume on the outcomes of cancer surgery has been well established. The present studies investigates how race/ethnicity influences the utilization of high-volume centers for hepatobiliary and pancreatic surgery. Methods: Patients that underwent surgery for hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (ICC), extrahepatic cholangiocarcinoma (ECC), ampullary adenocarcinoma (AC), or pancreatic ductal adenocarcinoma (PDAC) between 2006 and 2015 were identified from the National Cancer Data Base. Hospitals were divided into low- and high-volume centers based on the medium number of cancer surgeries per year. Multivariable logistic regression analyses predicting receipt of care at a low-volume center based on age, sex, race/ethnicity, comorbidities, insurance, income, travel distance, geographic location, urban/metro location, and tumor stage were performed. All analyses were performed separately by tumor type. Results: 8,962 patients with HCC, 2,119 with ICC, 3,973 with ECC, 5,125 with AC, and 25,231 with PDAC were identified. Non-Hispanic black patients were more likely to undergo resection for AC (vs. non-Hispanic white: AOR, 1.326; p = 0.0125) or PDAC (vs. non-Hispanic white: AOR, 1.187; p = 0.0002) at a low volume centers. Hispanic patients more often underwent surgery for ECC (vs. non-Hispanic white: AOR, 1.731; p &lt; 0.0001) or PDAC (vs. non-Hispanic white: 2.030; p &lt; 0.0001) cancer at a low-volume center. Patients of Asian descent were significantly less often treated for HCC at a low volume center (vs. non-Hispanic white: AOR, 0.644; p &lt; 0.0001) compared to non-Hispanic whites. Non-Hispanic black, Hispanic, or Asian race/ethnicity did not impact the likelihood of receiving care at a low volume center for any other tumor types. Conclusions: The results of this study suggest that race/ethnicity influences the likelihood of receiving care at a high-volume cancer center, even after controlling for other barriers to access to care, including insurance status, income and travel distance.

Reappraisal of Prognostic Impact of Tumor SUVmax by 18F-FDG-PET/CT in Intrahepatic Cholangiocarcinoma.

We previously reported that tumor standardized uptake value (SUVmax) by 18F-fluorodeoxyglucose-positron emission tomography/computed tomography (PET/CT) was a potential predictor in patients undergoing surgery for intrahepatic cholangiocarcinoma (ICC). However, the prognostic value of SUVmax in the era of multidisciplinary strategy has remained unclear. The aim of this study was to reappraise the prognostic value of tumor SUVmax in patients undergoing surgery for ICC. Data from 82 consecutive ICC patients, who underwent 18F-FDG-PET/CT and subsequent surgery between 2006 and 2017, were retrieved from a prospectively maintained institutional database. Adjuvant strategy was administrated during this study period in our center. Tumor SUVmax was associated with tumor size (p = 0.002) and tumor number (p = 0.005), but not associated with T and N stage classified by American Joint Committee on Cancer-classification system, and other tumor factors. According to the tumor SUVmax cut-off values of 8.0 based on the minimum p value approach, actuarial 5-year overall survival (OS) rates in patients undergoing upfront surgery for ICC were significantly stratified at 54.7% versus 26.0% (low vs. high tumor SUVmax group, p = 0.008). The actuarial 3-year disease-free survival (DFS) rates were also significantly stratified at 41.0% versus 18.3% (p < 0.001). Multivariate Cox regression analyses revealed that tumor SUVmax retained its significance on OS (p = 0.039) as well as DFS (p < 0.001). Even in the era of multidisciplinary strategy, high tumor SUVmax still represents poor prognosis in patients undergoing surgery for ICC. These patients, therefore, would probably be required more effective strategies.

Intrahepatic metastasis and lymph node metastasis are useful for determination of indications for surgery, borderline, or non-surgery in intrahepatic cholangiocarcinoma

Introduction: Intrahepatic cholangiocarcinoma (ICC) is a fatal disease because of frequent recurrence and poor survival despite curative surgery. We investigated the indications for surgery, borderline, or non-surgeryin patients with advanced ICC. Method: We retrospectively studied 194 patients with ICC who underwent curative surgery between 2000 and 2014. Prognostic factors for survival are evaluated on univariate and multivariate analyses. Result: The 5-year survival rate was significantly higher in patients without intrahepatic metastasis (IM: 53%) than in patients with IM (14%, p<0.0001). The 5-year survival rate was significantly higher in patients without lymph node metastasis (LNM: 55%) than in patients with LN (25%, p<0.0001). IM and LNM showed significant prognostic factor for survival on multivariate analysis (both, p<0.0001). According to the survival rates with IM and/or LNM, the 5-year survival rates were 61% in patients without IM or LNM, 41% in patients with LNM and without IM, 26% in patients with IM and without LNM, and 0% in patients with IM and LNM. Conclusion: Indication of surgery of patients with ICC can determine based on the IM and LNM.

The Relationship Between 18F-FDG Uptake on PET/CT and Markers of Systemic Inflammatory Response in Patients Undergoing Surgery for Intrahepatic Cholangiocarcinoma.

This study evaluated the prognostic relationship between tumor 18F-fluorodeoxyglucose (FDG) uptake on positron-emission tomography (PET)/computed tomography (CT) imaging and markers of systemic inflammatory response (SIR) in patients undergoing surgery for intrahepatic cholangiocarcinoma (ICC). Between 2002 and 2016, 94 patients with ICC who underwent 18F-FDG-PET scans before surgery were analyzed. 18F-FDG uptake was quantified as a maximum standardized uptake value (SUVmax). The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and C-reactive protein (CRP) were selected as SIR markers. There was no strong correlation between SUVmax and, NLR, PLR and CRP (all Pearson's |r| <0.40). Multivariate Cox regression analyses identified high tumor SUVmax (≥8) and high NLR (≥5) as independent predictors of poor overall survival (p=0.013 and p=0.002) and disease-free survival (p<0.001 and p=0.004). Prognostic information provided by tumor SUVmax and SIR markers may be independent prognostic factors in patients undergoing surgery for ICC.

Our Rationale of Initiating Neoadjuvant Chemotherapy for Hilar Cholangiocarcinoma: A Proposal of Criteria for "Borderline Resectable" in the Field of Surgery for Hilar Cholangiocarcinoma.

The concept of "borderline resectable" was recently introduced to the field of surgery for pancreatic cancer, and surgical outcomes for this disease with extremely dismal prognosis have improved since the introduction of this concept. However, no such concept has yet been introduced to the field of surgery for hilar cholangiocarcinoma (HCca). To determine a definition and criteria for "borderline resectable" in the field of surgery for HCca. Retrospective analysis of 88 patients undergoing curative-intent surgery for HCca at our institution between May 1992 and December 2008 to clarify independent prognostic factors. Survival outcomes were obtained for these 88 patients, with a 5-year overall survival rate of 31.8%. Independent factors predictive of cancer death were determined by multivariate analysis to be the presence of regional lymph node metastasis (LNM) and pathological confirmed vascular invasion (VI). Cumulative survival rates of 23 patients with both LNM and VI who underwent surgery were significantly worse than those of the remaining 65 surgically treated patients and similar to those of 26 patients who were considered to have unresectable disease and treated with non-surgical multidisciplinary treatment during the same study period. Outcomes of surgery for cases of HCca showing regional LNM and VI were no better than those of non-surgical treatment for unresectable disease. Coexistence of these two factors indicates oncologically dismal condition and thus such cases should be considered "borderline resectable." Treatments additional to surgery are required for "borderline resectable" cases to obtain better outcomes.

Surgical Outcomes for Perihilar Cholangiocarcinoma with Vascular Invasion

PurposeTo investigate short- and long-term surgical outcomes for patients with perihilar cholangiocarcinoma and vascular invasion. MethodsData from 249 patients who underwent perihilar cholangiocarcinoma surgery between 2000 and 2016 were retrospectively analyzed. Patient evaluations included short-term surgical outcomes following vascular resection and long-term outcomes in cases with histopathological vascular invasion. ResultsMortality was 3.6% overall; 16% for hepatic artery resections, 5.4% for portal vein resections, and 1.7% in the absence of vascular resection (p = 0.029). No between-group differences were observed in the incidence of Clavien–Dindo grade ≥ 3 complications. The factors related to perioperative mortality were hepatic artery resection (odds ratio [OR] = 25.5), right trisectionectomy (OR = 13.0), and central bisectionectomy (OR = 13.8). Multivariate analysis for overall survival identified several prognostic factors: carcinoembryonic antigen level ≥ 5 ng/mL (hazard ratio [HR] = 1.68), poor differentiation (HR = 2.39), distant metastasis (HR = 1.97), and R1 invasive resection (HR = 2.13). Five-year overall survival for patients with portal vein invasion and M0R0/1cis was 35.6%, significantly worse than the 53.4% for patients with no portal vein invasion and M0R/1cis but better than the 0% for patients with portal vein invasion and M1 or R1. Those with hepatic arterial invasion and M0R0/1cis were 24.7%, significantly worse than the 53.4% for patients with no hepatic arterial invasion and M0R0/1cis but significantly better than the 0% for patients with hepatic arterial invasion and M1 or R1. ConclusionShort-term outcomes for patients with perihilar cholangiocarcinoma and undergoing vascular resection were poor compared to those without vascular resection. Long-term survival in R0M0 disease was more favorable; aggressive surgery is recommended.

Radio-frequency assisted liver partition with portal vein embolization in staged liver resection (RALPPS) in patients with hilar and intrahepatic cholangiocarcinoma

Objective: Estimation of the short-term results of Radio-frequency Assisted Liver Partition with Portal vein embolization in Staged liver resection (RALPPS) compared with Portal Vein Embolization (PVE) and subsequent major liver resection in patients with hilar (h-CCA) and intrahepatic (i-CCA) cholangiocarcinoma. Summary background data: Unsatisfactory immediate outcomes of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in surgery of cholangiocarcinoma suggested that patients with biliary cancer should not be treated by ALPPS. Short-term results of ALPPS variants with reduced surgical trauma on the first stage in patients with cholangiocarcinoma were not yet estimated. Methods: RALPPS and PVE were applied in 10 and 18 patients respectively. Future liver remnant (FLR) was estimated by CT. The propensity score matching method was used in compared groups. Results: The mean rate of FLR hypertrophy after RALPPS/PVE before and after matching was 42%/32% and 49%/31%, respectively. The mean duration of hypertrophy after RALPPS/PVE before and after matching was 16/20 days and 14/17 days, respectively. Major morbidity rate (IIIa grade, Clavien-Dindo) after the stage 1 was significantly larger for RALPPS before matching. There were no differences in morbidity of stage 1 after matching as well as for stage 2 before and after matching. Conclusions: According to preliminary short-term results estimation RALPPS may be considered as an effective and safe minimally invasive variant of ALPPS for rapid FLR hypertrophy in patients with h-CCA and i-CCA.