Liver Resection For Hilar Cholangiocarcinoma Research Articles

The Impact of KRAS Mutational Status on Long-Term Survival following Liver Resection for Hilar Cholangiocarcinoma.

Simple SummaryThe reported frequency of KRAS mutations and their prognostic impact in patients resected for hilar cholangiocarcinoma are controversial. The aim of this study was to evaluate the rate of KRAS mutations in a single-center homogeneous population resected for hilar cholangiocarcinoma and the impact on prognosis. The frequency of KRAS mutations was 22.2%. KRAS mutation was not related with pathologic characteristics of the tumor. Patients with a KRAS mutation presented zero 5-year OS that was significantly lower than that observed in patients with KRAS wild type (5-year OS = 49.2%, p = 0.003). In the multivariable analysis, KRAS mutation was an independent strong predictor of poor OS. KRAS mutation analysis should be included in the routine pathologic evaluation of resected hilar cholangiocarcinoma in order to better stratify prognosis.KRAS mutation is reportedly associated with poor prognosis in patients with different cancer types. However, mutational data on hilar cholangiocarcinoma are few and controversial. The aim of this study was to evaluate the rate of KRAS mutations in a single-center homogeneous population resected for hilar cholangiocarcinoma and the subsequent impact on prognosis. KRAS mutation status was evaluated in 54 patients undergoing major hepatectomy combined with resection of the main biliary confluence and regional lymphadenectomy for hilar cholangiocarcinoma between 2001 and 2019. Among these 54 patients, 12 (22.2%) had a KRAS mutation. KRAS mutation was not related with pathologic characteristics of the tumor. Five-year overall survival (OS) in patients with KRAS mutation was significantly lower than that observed in patients with KRAS wild type (0 vs. 49.2%, respectively; p = 0.003). In the multivariable analysis; independent predictors of poor OS were KRAS mutation (HR = 5.384; p = 0.003) and lymph node metastases (HR = 2.805; p = 0.023). The results of our study suggested that KRAS mutation in hilar cholangiocarcinoma was not rarely observed. KRAS mutation was an independent strong predictor of poor OS. KRAS mutation analysis should be included in the routine pathologic evaluation of resected hilar cholangiocarcinoma in order to better stratify prognosis

Minor liver resection for hilar cholangiocarcinoma of Bismuth-Corlette type Ⅲ and Ⅳ

Objective: To explore the clinical effect and safety of minor liver resection for hilar cholangiocarcinoma (HC) of Bismuth-Corlette type Ⅲ and Ⅳ. Methods: From May 2007 to May 2017, the clinical data of 108 patients with Bismuth-Corlette type Ⅲ and Ⅳ HC underwent hepatectomy were collected and analyzed retrospectively.There were 56 males and 52 females, aged (57.2±5.3) years (ranged 48-76 years) .Among the 108 cases, there were 51 cases of type Ⅲa, 40 cases of type Ⅲb and 17 cases of type Ⅳ. Small-scale hepatectomy (≤3 hepatectomy) was performed in 70 cases, including 8 cases of 4b segment resection, 28 cases of 4b segment+5 segment resection, and 34 cases of partial 4 segment+partial 7 segment+partial 1 segment resection. Large-scale hepatectomy was performed in 38 cases (>3 segments) , of which 30 cases were treated with 2 segments+3 segments+4 segments+1 segment, and 8 cases were treated with 5 segments+7 segments+8 segments+1 segment. t' test was used to analyze the data which did not conform to the normal distribution, and χ(2) test was used to calculate the incidence of postoperative complications and the 1, 3, and 5-year cumulative overall survival rate. Results: (1) The operation time of minor liver resection group ((180±25)minutes) was shorter than that of major liver resection group ((210±35)minutes) (t'=4.676, P<0.05) , the amount of blooding operation time of minor liver resection group ((310±80)ml) was less than that of major liver resection group ((500±110)ml)in the operation (t'=9.385, P<0.05) , and the difference was statistically significant. (2) The incidence of complications was lower in minor liver resection group and major liver resection group, and the difference was statistically significant (χ(2)=5.230, P<0.05) . (3) The actual 1-, 3- and 5-year survival rates were 87.1%, 58.4%, 30.0% and 84.2%, 57.9%,31.6%, respectively. There were no significant differences in survival rates in two groups in 1-, 3- and 5-year survival rates (χ(2)=0.177, P=0.674; χ(2)=0.005, P=0.946; χ(2)=0.029, P=0.865) . Conclusions: Compared to patients with major liver resection, Minor liver resection for selected patients with HC of Bismuth-Corlette Ⅲ and Ⅳaccording to our criteria achieved better long-term outcomes. Chen's biliojejunostomy is a simple, effective and safe method, which can be widely used when there are multiple biliary intestinal anastomosese.

Outcomes of liver resection for hilar cholangiocarcinoma of bismuth type III and IV: a minor versus major approach

Background: Combined liver resection for hilar cholangiocarcinoma (HCCA) of Bismuth type III and IV is now adopted by most surgeons. However, the optimal extent of hepatic resection to achieve negative margin still remains controversial. Methods: Between March 2006 and March 2016, 78 consecutive patients with Bismuth type III and IV HCCA underwent surgical resection with curative intent. Patients were classified into two groups: minor liver resection group (n = 46) and major liver resection group B (n = 32). The preioperative outcomes and long-term outcomes including overall or disease-free survival rate were compared. Results: The major liver resection group had significantly higher R0 resection rates compared with the minor liver resection group (84.4% versus 60.1%, p = 0.025), albeit with higher blood transfusion requirements (62.5% versus 23.9%, p < 0.001) and longer length hospital stay (26.75 ± 10.29 versus 20.48±6.90, p = 0.002). Comparing with minor liver resection, major liver resection resulted in significantly higher general complications (34% versus 13%, p = 0.025), but it showed better overall survival (OS) (p = 0.006) and disease-free survival (p = 0.041). Conclusion: Major liver resection, after biliary drainage and preoperative portal vein embolization, when necessary, should be considered in patients with Bismuth type III and IV HCCA.

Outcomes of liver resection for hilar cholangiocarcinoma of bismuth type III and IV: a minor versus major approach

Background: Combined liver resection for hilar cholangiocarcinoma (HCCA) of Bismuth type III and IV is now adopted by most surgeons. However, the optimal extent of hepatic resection to achieve negative margin still remains controversial. Methods: Between March 2006 and March 2016, 78 consecutive patients with Bismuth type III and IV HCCA underwent surgical resection with curative intent. Patients were classified into two groups: minor liver resection group (n = 46) and major liver resection group B (n = 32). The preioperative outcomes and long-term outcomes including overall or disease-free survival rate were compared. Results: The major liver resection group had significantly higher R0 resection rates compared with the minor liver resection group (84.4% versus 60.1%, P = 0.025), albeit with higher blood transfusion requirements (62.5% versus 23.9%, P < 0.001) and longer length hospital stay (26.75±10.29 versus 20.48±6.90, P = 0.002). Comparing with minor liver resection, major liver resection resulted in significantly higher general complications (34% versus 13%, P = 0.025), but it showed better overall survival (OS) (P = 0.006) and disease-free survival (P = 0.041). Conclusion: Major liver resection, after biliary drainage and preoperative portal vein embolization, when necessary, should be considered in patients with Bismuth type III and IV HCCA.

Liver resection for hilar cholangiocarcinoma in patients over 70 years: does preoperative cholangitis exclude older patients from surgery?

Liver resection for hilar cholangiocarcinoma in patients over 70 years: does preoperative cholangitis exclude older patients from surgery?

Liver resection for hilar cholangiocarcinoma in patients over 70 years: does preoperative cholangitis exclude older patients from surgery?

Liver resection for hilar cholangiocarcinoma in patients over 70 years: does preoperative cholangitis exclude older patients from surgery?

Association of Lymph Node Status With Survival in Patients After Liver Resection for Hilar Cholangiocarcinoma in an Italian Multicenter Analysis

The prognostic value of lymph node (LN) assessment after liver resection for hilar cholangiocarcinoma (HC) is still controversial, and the number of LNs required to be removed to obtain adequate staging is not well defined. To evaluate the LN status in patients after liver resection for HC and to clarify which prognostic factor (the number of positive LNs or the LN ratio [LNR]) was most accurate for staging and what minimum number of retrieved LNs was required for adequate staging. Retrospective multicenter study of patients who underwent resection for HC between January 1, 1992, and December 31, 2007, at 8 hepatobiliary Italian centers. The last follow-up was assessed in July 2014. Differences in overall survival (OS) according to the LN status were analyzed. The OS results were defined as actual because all included patients completed a 5-year follow-up. One-hundred seventy-five patients with 1133 retrieved LNs were analyzed. The mean (SD) age of the cohort was 63 (10) years, and 42.9% (75 of 175) were female. The median number of LNs examined per patient was 6.5. Forty percent (70 of 175) had LN metastasis. An LNR exceeding 0.20 was associated with significantly lower 5-year OS than an LNR of 0.20 or less (10.6% vs 24.4%; odds ratio, 2.434; 95% CI, 1.020-5.810; P = .04). On multivariable analysis, the LNR was the only independent prognostic factor for OS but was influenced by the total number of retrieved LNs. The LNR was greater than 0.20 in all patients (30 of 30) with 1 to 4 retrieved LNs and in 52.5% (21 of 40) of patients with at least 5 retrieved LNs. Five-year OS in patients with 1 to 5 retrieved LNs was significantly lower than that in those with 6 to 7 retrieved LNs and those with at least 8 retrieved LNs (34.2%, 64.5%, and 62.7%, respectively; P = .047). Five-year OS did not significantly improve when the number of retrieved LNs was greater than 6. These results were confirmed in a receiver operating characteristic curve analysis performed among N0R0 patients, in whom 5 retrieved LNs was the most accurate cutoff to predict 5-year actual OS (area under the curve, 0.624; P = .004). An LNR exceeding 0.20 was the only independent prognostic factor for OS in N1 patients after liver resection for HC. However, the LNR was influenced by the total number of retrieved LNs, and removal of more than 5 LNs was the minimum number of LNs required for adequate staging.

Tumour size over 3 cm predicts poor short-term outcomes after major liver resection for hilar cholangiocarcinoma. By the HC-AFC-2009 group

IntroductionAs mortality and morbidity after a curative resection remains high, it is essential to identify pre-operative factors associated with an early death after a major resection. MethodsBetween 1998 and 2008, we selected a population of 331 patients having undergone a major hepatectomy including segment I with a lymphadenectomy and a common bile duct resection for a proven hilar cholangiocarcinoma in 21 tertiary centres. The study's objective was to identify pre-operative predictors of early death (<12 months) after a resection. ResultsThe study cohort consisted of 221 men and 110 women, with a median age of 61 years (range: 24–85). The post-operative mortality and morbidity rates were 8.2% and 61%, respectively. The 1-, 3- and 5-year overall survival rates were 85%, 64% and 53%, respectively. The median tumour size was 23 mm on pathology, ranging from 8 to 40. A tumour size >30 mm [odds ratio (OR) 2.471 (95% confidence interval (CI) 1.136–7.339), P = 0.001] and major post-operative complication [OR 3.369 (95% CI 1.038–10.938), P = 0.004] were independently associated with death <12 months in a multivariate analysis. ConclusionThe present analysis of a series of 331 patients with hilar cholangiocarcinoma showed that tumour size >30 mm was independently associated with death <12 months.

Unilateral versus bilateral endoscopic biliary stenting for malignant hilar biliary strictures

The present review compared unilateral versus bilateral stenting in order to determine the optimal stenting strategy for malignant hilar biliary strictures based on the previous literature. The role of preoperative biliary drainage prior to liver resection for hilar cholangiocarcinoma remains under discussion. However, in Japan, endoscopic placement of single nasobiliary drainage in the future remnant hepatic lobe is currently considered the most suitable method. In most unresectable cases, unilateral stenting appears to be adequate for ameliorating jaundice. It is technically easier and less expensive than bilateral stenting, with reintervention for stent dysfunction also being considerably easier. However, contrast medium injection into undrained bile ducts is associated with uncontrolled cholangitis and poor prognosis. To prevent this complication, bilateral stenting may be preferred to unilateral stenting. Additionally, previous studies have demonstrated bilateral stenting to be associated with longer stent patency as compared to unilateral stenting. We consider that further large-scale studies are required to clarify whether unilateral or bilateral stenting is a better therapeutic technique for malignant hilar biliary stricture.

Oncological Superiority of Hilar En Bloc Resection for the Treatment of Hilar Cholangiocarcinoma

Long-term results after liver resection for hilar cholangiocarcinoma are still not satisfactory. Previously, we described a survival advantage of patients who undergo combined right trisectionectomy and portal vein resection, a procedure termed "hilar en bloc resection." The present study was conducted to analyze its oncological effectiveness compared to conventional hepatectomy. During hilar en bloc resection, the extrahepatic bile ducts were resected en bloc with the portal vein bifurcation, the right hepatic artery, and liver segments 1 and 4 to 8. With this "no-touch" technique, preparation of the hilar vessels in the vicinity of the tumor was avoided. The long-term outcome of 50 consecutive patients who underwent curative (R0) hilar en bloc resection between 1990 and 2004 was compared to that of 50 consecutive patients who received curative conventional major hepatectomy for hilar cholangiocarcinoma (perioperative deaths excluded). The 1-, 3-, and 5-year survival rates after hilar en bloc resection were 87%, 70%, and 58%, respectively, which was significantly higher than after conventional major hepatectomy. In the latter group, 1-, 3-, and 5-year survival rates were 79%, 40%, and 29%, respectively (P = 0.021). Tumor characteristics were comparable in both groups. A high number of pT3 and pT4 tumors and patients with positive regional lymph nodes were present in both groups. Multivariate analysis identified hilar en bloc resection as an independent prognostic factor for long-term survival (P = 0.036). In patients with central bile duct carcinomas, hilar en bloc resection is oncologically superior to conventional major hepatectomy, providing a chance of long-term survival even in advanced tumors.

Extent of liver resection for hilar cholangiocarcinoma

The extent of liver resection for hilar cholangiocarcinoma (HC) remains controversial despite extensive studies. The aim of this study was to determine the safety and efficacy of minor and major hepatectomy, selected by predetermined criteria in patients with HC. From 2000 to 2007, 187 patients with HC were studied prospectively; 138 patients underwent resection with curative intent. Minor hepatectomy was performed in 93 patients with Bismuth-Corlette type I, II or III HC without hepatic arterial or portal venous invasion, and major hepatectomy in 45 patients with type III HC with hepatic arterial or portal venous invasion, or type IV HC. Overall mortality and morbidity rates were 0 and 29.7 per cent respectively, and the bile leak rate was 1.4 per cent. Actuarial 1-, 3- and 5-year survival rates were 87, 54 and 34 per cent respectively in the minor liver resection group, and 80, 42 and 27 per cent for major resection (P = 0.300). Minor liver resection for HC, selected by predetermined criteria, had good results. Major liver resection, which had a higher operative morbidity rate than minor resection, should be reserved for Bismuth-Corlette type III HC with vascular invasion, or type IV HC.

Role of preoperative biliary drainage of liver remnant prior to extended liver resection for hilar cholangiocarcinoma

BackgroundIn patients with hilar cholangiocarcinoma, ipsilateral en bloc hepatic resection improves survival but is associated with increased morbidity. Preoperative biliary drainage of the future liver remnant (FLR) and contralateral portal vein embolization (PVE) may improve perioperative outcome, but their routine use is controversial. This study analyses the impact of FLR volume and preoperative biliary drainage on postoperative hepatic insufficiency and mortality rates. MethodsPatients who underwent hepatic resection and for whom adequate imaging data for FLR calculation were available were identified retrospectively. Patient demographic, operative and perioperative data were recorded and analysed. The volume of the FLR was calculated based on the total liver volume and the volume of the resection that was actually performed using semi-automated contouring of the liver on preoperative helical acquired scans. In patients subjected to preoperative biliary drainage, the preoperative imaging was reviewed to determine if the FLR had been decompressed. Hepatic insufficiency was defined as a postoperative rise in bilirubin of 5mg/dl above the preoperative level that persisted for >5 days postoperatively. Operative mortality was defined as death related to the operation, whenever it occurred. ResultsSixty patients were identified who underwent hepatic resection between 1997 and 2007 and for whom imaging data were available for analysis. During this period, preoperative biliary drainage of the FLR was used selectively and PVE was used in only one patient. The mean age of the patients was 64 ± 11.6 years and 68% were male. The median length of stay was 14 days and the overall morbidity and mortality were 53% and 10%, respectively. Preoperative FLR volume was a predictor of hepatic insufficiency and death (P= 0.03). A total of 65% of patients had an FLR volume ≥30% (39/60) of the total volume. No patient in this group had hepatic insufficiency, but there were two operative deaths (5%), both occurring in patients who underwent preoperative biliary drainage. By contrast, in the group with FLR < 30% (21/60, 35%), hepatic insufficiency was seen in five patients and operative mortality in four patients, and were strongly associated with lack of preoperative biliary drainage of the FLR (P= 0.009). Patients with an FLR ≥ 30% were more likely to have radiographic evidence of ipsilateral lobar atrophy and hypertrophy of the FLR (46.2% vs. 9.5% in patients with FLR < 30%; P= 0.004). ConclusionsIn patients undergoing liver resection for hilar cholangiocarcinoma, FLR volume of < 30% of total liver volume is associated with increased risk for hepatic insufficiency and death. Preoperative biliary drainage of the FLR appears to improve outcome if the predicted volume is < 30%. However, in patients with FLR ≥ 30%, preoperative biliary drainage does not appear to improve perioperative outcome and, as many of these patients have hypertrophy of the FLR, PVE is likely to offer little benefit.

W1521 Safe Liver Resection for Hilar Cholangiocarcinoma Without Preoperative Biliary Drainage and Portal Vein Embolization

W1521 Safe Liver Resection for Hilar Cholangiocarcinoma Without Preoperative Biliary Drainage and Portal Vein Embolization

Extrahepatic bile duct resection in combination with liver resection for hilar cholangiocarcinoma: a report of 42 cases.

From September 1986 until December 2001, 42 patients (20 males and 22 females) underwent a combined extrahepatic bile duct resection (EHBDR) and liver resection (LR) for hilar cholangiocarcinoma (HC). The aim of this study was to analyze patient survival, morbidity, and mortality as well as to seek predictive factors. The 1-, 3-, and 5-year actuarial patient survival was 72%, 37%, and 22%, respectively. Median survival was 19 months. Hospital mortality, all due to septic complications, was 12%. Morbidity was observed in 32 patients (76%). Infections were the most dominant complication. Patients (n=11) with American Joint Committee on Cancer (AJCC) stage I or stage II tumors exhibited a superior survival compared with patients (n=31) with stage III or IV tumors (p=0.023). Patients with tumor-free lymph nodes (n=26) indicated a greater survival compared with patients with tumor-positive lymph nodes (n=16) (p=0.004). Patients undergoing vascular reconstructions indicated a trend toward higher mortality and lower survival (p=0.068). Over 20% of the patients with hilar cholangiocarcinoma can survive more than 5 years after a combined EHBDR and LR at the cost of 12% perioperative mortality and a 76% morbidity. Results might improve with the prevention of infectious complications and improved selection of patients to avoid vascular reconstruction and to predict a negative nodal state.