Liver Resection For Perihilar Cholangiocarcinoma Research Articles

Higher Postoperative Mortality and Inferior Survival After Right-Sided Liver Resection for Perihilar Cholangiocarcinoma: Left-Sided Resection is Preferred When Possible.

A right- or left-sided liver resection can be considered in about half of patients with perihilar cholangiocarcinoma (pCCA), depending on tumor location and vascular involvement. This study compared postoperative mortality and long-term survival of right- versus left-sided liver resections for pCCA. Patients who underwent major liver resection for pCCA at 25 Western centers were stratified according to the type of hepatectomy-left, extended left, right, and extended right. The primary outcomes were 90-day mortality and overall survival (OS). Between 2000 and 2022, 1701 patients underwent major liver resection for pCCA. The 90-day mortality was 9% after left-sided and 18% after right-sided liver resection (p<0.001). The 90-day mortality rates were 8% (44/540) after left, 11% (29/276) after extended left, 17% (51/309) after right, and 19% (108/576) after extended right hepatectomy (p<0.001). Median OS was 30 months (95% confidence interval [CI] 27-34) after left and 23 months (95% CI 20-25) after right liver resection (p<0.001), and 33 months (95% CI 28-38), 27 months (95% CI 23-32), 25 months (95% CI 21-30), and 21 months (95% CI 18-24) after left, extended left, right, and extended right hepatectomy, respectively (p<0.001). A left-sided resection was an independent favorable prognostic factor for both 90-day mortality and OS compared with right-sided resection, with similar results after excluding 90-day fatalities. A left or extended left hepatectomy is associated with a lower 90-day mortality and superior OS compared with an (extended) right hepatectomy for pCCA. When both a left and right liver resection are feasible, a left-sided liver resection is preferred.

The impact of post-hepatectomy liver failure on long-term survival after liver resection for perihilar cholangiocarcinoma

BackgroundAlthough post-hepatectomy liver failure (PHLF) can accurately predict short-term mortality of liver resection for perihilar cholangiocarcinoma (pCCA), its significance in predicting long-term overall survival (OS) is still uncertain. MethodsRetrospective analysis was performed on patients with pCCA who underwent liver resection between October 2013 and December 2018. The patients were divided into 3 groups; No PHF, PHLF (all grade) and grade B/C PHLF according to The International Study Group of Liver Surgery (ISGLS) criteria. ResultsA total of 177 patients were enrolled, 65 (36.7%) had PHLF; 25 (14.1%) had grade A, and 40 (22.6%) had grade B/C. Prior to surgery, patients with PHLF showed significantly greater bilirubin levels and CA 19-9 level than those without (11.5 vs 6.7 mg/dL, p = 0.002 and 232.4 vs 85.9 U/mL, p = 0.005, respectively). Additionally, pre-operative future liver remnant volume in PHLF group was lower than no PHLF group significantly (39.6% vs 43.5%, p = 0.006). Major complication and 90-day mortality were higher in PHLF group than no PHLF group (69.2% vs 20.5%, p < 0.001 and 29.2% vs 3.6%, p < 0.001, respectively). The OS in both grade A PHLF and grade B/C PHLF was significantly worse compared to no PHLF, with median survival times of 8.4, 3.3, and 19.2 months, respectively (p < 0.001 and p < 0.001, respectively). Multivariable analysis revealed that PHLF was independently prognostic factor for long-term survival. ConclusionTo achieve negative resection margin, the surgical resection in pCCA was aggressive, however this increased the risk of PHLF, which also affects the OS. Consequently, it is necessary for establishing a balance between aggressive surgery and PHLF.

Comparing Liver Venous Deprivation and Portal Vein Embolization for Perihilar Cholangiocarcinoma: Is It Time to Shift the Focus to Hepatic Functional Reserve Rather than Hypertrophy?

Purpose: Among liver hypertrophy technics, liver venous deprivation (LVD) has been recently introduced as an effective procedure to combine simultaneous portal inflow and hepatic outflow abrogation, raising growing clinical interest. The aim of this study is to investigate the role of LVD for preoperative optimization of future liver remnant (FLR) in perihilar cholangiocarcinoma (PHC), especially when compared with portal vein embolization (PVE). Methods: Between January 2013 and July 2022, all patients diagnosed with PHC and scheduled for preoperative optimization of FTR, through radiological hypertrophy techniques, prior to liver resection, were included. FTR volumetric assessment was evaluated at two distinct timepoints to track the progression of both early (T1, 10 days post-procedural) and late (T2, 21 days post-procedural) efficacy indicators. Post-procedural outcomes, including functional and volumetric analyses, were compared between the LVD and the PVE cohorts. Results: A total of 12 patients underwent LVD while 19 underwent PVE. No significant differences in either post-procedural or post-operative complications were found. Post-procedural FLR function, calculated with (99m) Tc-Mebrofenin hepatobiliary scintigraphy, and kinetic growth rate, at both timepoints, were greater in the LVD cohort (3.12 ± 0.55%/min/m2 vs. 2.46 ± 0.64%/min/m2, p = 0.041; 27.32 ± 16.86%/week (T1) vs. 15.71 ± 9.82%/week (T1) p < 0.001; 17.19 ± 9.88%/week (T2) vs. 9.89 ± 14.62%/week (T2) p = 0.034) when compared with the PVE cohort. Post-procedural FTR volumes were similar for both hypertrophy techniques. Conclusions: LVD is an effective procedure to effectively optimize FLR before liver resection for PHC. The faster growth rate combined with the improved FLR function, when compared to PVE alone, could maximize surgical outcomes by lowering post-hepatectomy liver failure rates.

Multivariable prediction model for both 90-day mortality and long-term survival for individual patients with perihilar cholangiocarcinoma: does the predicted survival justify the surgical risk?

The risk of death after surgery for perihilar cholangiocarcinoma is high; nearly one in every five patients dies within 90 days after surgery. When the oncological benefit is limited, a high-risk resection may not be justified. This retrospective cohort study aimed to create two preoperative prognostic models to predict 90-day mortality and overall survival (OS) after major liver resection for perihilar cholangiocarcinoma. Separate models were built with factors known before surgery using multivariable regression analysis for 90-day mortality and OS. Patients were categorized in three groups: favourable profile for surgical resection (90-day mortality rate below 10 per cent and predicted OS more than 3 years), unfavourable profile (90-day mortality rate above 25 per cent and/or predicted OS below 1.5 years), and an intermediate group. A total of 1673 patients were included. Independent risk factors for both 90-day mortality and OS included ASA grade III-IV, large tumour diameter, and right-sided hepatectomy. Additional risk factors for 90-day mortality were advanced age and preoperative cholangitis; those for long-term OS were high BMI, preoperative jaundice, Bismuth IV, and hepatic artery involvement. In total, 294 patients (17.6 per cent) had a favourable risk profile for surgery (90-day mortality rate 5.8 per cent and median OS 42 months), 271 patients (16.2 per cent) an unfavourable risk profile (90-day mortality rate 26.8 per cent and median OS 16 months), and 1108 patients (66.2 per cent) an intermediate risk profile (90-day mortality rate 12.5 per cent and median OS 27 months). Preoperative risk models for 90-day mortality and OS can help identify patients with resectable perihilar cholangiocarcinoma who are unlikely to benefit from surgical resection. Tailored shared decision-making is particularly essential for the large intermediate group.

The efficiency of postoperative liver failure and mortality risk scores after liver resection for perihilar cholangiocarcinoma.

The efficiency of postoperative liver failure and mortality risk scores after liver resection for perihilar cholangiocarcinoma.

Validation study of postoperative liver failure and mortality risk scores after liver resection for perihilar cholangiocarcinoma.

Surgery for perihilar cholangiocarcinoma (PHCC) remains a challenging procedure with high morbidity and mortality. The Academic Medical Center (Amsterdam UMC) and Memorial Sloan Kettering Cancer Center proposed a postoperative mortality risk score (POMRS) and post-hepatectomy liver failure score (PHLFS) to predict patient outcomes. This study aimed to validate the POMRS and PHLFS for PHCC patients at Hokkaido University. Medical records of 260 consecutive PHCC patients who had undergone major hepatectomy with extrahepatic bile duct resection without pancreaticoduodenectomy at Hokkaido University between March 2001 and November 2018 were evaluated to validate the PHLFS and POMRS. The observed risks for PHLF were 13.7%, 24.5%, and 39.8% for the low-risk, intermediate-risk, and high-risk groups, respectively, in the study cohort. A receiver-operator characteristic (ROC) analysis revealed that the PHLFS had moderate predictive value, with an analysis under the curve (AUC) value of 0.62. Mortality rates based on the POMRS were 1.7%, 5%, and 5.1% for the low-risk, intermediate-risk, and high-risk groups, respectively. The ROC analysis demonstrated an AUC value of 0.58. This external validation study showed that for PHLFS the threshold for discrimination in an Eastern cohort was reached (AUC >0.6), but it would require optimization of the model before use in clinical practice is acceptable. The POMRS were not applicable in the eastern cohort. Further external validation is recommended.

Primary and Secondary Liver Failure after Major Liver Resection for Perihilar Cholangiocarcinoma

Primary and Secondary Liver Failure after Major Liver Resection for Perihilar Cholangiocarcinoma

The Learning Curve of Hepatobiliary Robotic Surgery: The First 100 Cases

Introduction: Minimally invasive surgery has been increasingly and successfully used across different surgical areas. Minimally invasive liver surgery (MILS) is an expanding field, and robotic surgery is currently in the frontline. The authors present the first Portuguese robotic liver surgery series. Methods: Clinical-pathological data was prospectively collected between October 2019 and August 2021. A retrospective review of the most relevant variables and results was performed. Statistical analysis was performed using SPSS 26. Results: At our institution, 100 consecutive patients were submitted to robotic hepatobiliary surgery. Median age was 60 years old (18-80). Malignancy was the most frequent indication for surgery n=67 (Liver colorectal metastasis n=36, hepatocellular carcinoma n=17, cholangiocarcinoma n=4). 39 patients were submitted to a major hepatectomy and the average intervention duration was 253 min (70-740min). Starting with minor operations, increasingly complex procedures, such as central hepatectomy of liver resection for perihilar cholangiocarcinoma, were performed. Conversion rate to open surgery was 3%, and average blood loss was 226cc. Three patients required transfusional support during the perioperative period. We report a morbidity rate of 13% (major: 4 patients) and a mortality rate of 1%. The median duration of post-operative hospital stay was 4 days (1-19). Conclusion: This represents the first and only reported Portuguese series of robotic hepatobiliary surgery. Robotic surgery can be safely performed for major liver resections with a low rate of conversion and post-operative complications. The introduction of robotics may be one of the most significant recent achievements in the field of liver surgery.

Impact of Body Mass Index on Tumor Recurrence in Patients Undergoing Liver Resection for Perihilar Cholangiocarcinoma (pCCA).

Simple SummaryPerihilar cholangiocarcinoma (pCCA) is a relatively rare and aggressive hepatobiliary tumor with a general poor prognosis. Surgical therapy remains the only curative treatment option with the best prospects for long-term survival. However, tumor recurrence is frequent, and is associated with a poor prognosis. The identification of risk factors as well as appropriate selection of surgical candidates is essential to accurately predict prognosis and to maximize survival while decreasing tumor recurrence rates. Previous studies have already established a link between an increased BMI and the occurrence of various tumors. At present, data on BMI-associated long-term outcome following curative liver resection in pCCA patients are warranted. This study aims to investigate the impact of increased BMI on patient’s outcome, especially on tumor recurrence, following liver resection in patients with pCCA as well as to evaluate prognostic and risk factors for accurate prediction of outcome in this selective group of patients.Background: The association of body mass index (BMI) and long-term prognosis and outcome of patients with perihilar cholangiocarcinoma (pCCA) has not been well defined. The aim of this study was to evaluate clinicopathologic and oncologic outcomes with pCCA undergoing resection, according to their BMI. Methods: Patients undergoing liver resection in curative intention for pCCA at a tertiary German hepatobiliary (HPB) center were identified from a prospective database. Patients were classified as normal weight (BMI 18.5–24.9 kg/m2), overweight (BMI 25.0–29.9 kg/m2) and obese (>30 kg/m2) according to their BMI. Impact of clinical and histo-pathological characteristics on recurrence-free survival (RFS) were assessed using Cox proportional hazard regression analysis among patients of all BMI groups. Results: Among a total of 95 patients undergoing liver resection in curative intention for pCCA in the analytic cohort, 48 patients (50.5%) had normal weight, 33 (34.7%) were overweight and 14 patients (14.7%) were obese. After a median follow-up of 4.3 ± 2.9 years, recurrence was observed in totally 53 patients (56%). The cumulative recurrence probability was higher in obese and overweight patients than normal weight patients (5-year recurrence rate: obese: 82% versus overweight: 81% versus normal weight: 58% at 5 years; p = 0.02). Totally, 1-, 3-, 5- and 10-year recurrence-free survival rates were 68.5%, 44.6%, 28.9% and 13%, respectively. On multivariable analysis, increased BMI (HR 1.08, 95% CI: 1.01–1.16; p = 0.021), poor/moderate tumor differentiation (HR 2.49, 95% CI: 1.2–5.2; p = 0.014), positive lymph node status (HR 2.01, 95% CI: 1.11–3.65; p = 0.021), positive resection margins (HR 1.89, 95% CI:1.02–3.4; p = 0.019) and positive perineural invasion (HR 2.92, 95% CI: 1.02–8.3; p = 0.045) were independent prognostic risk factors for inferior RFS. Conclusion: Our study shows that a high BMI is significantly associated with an increased risk of recurrence after liver resection in curative intention for pCCA. This factor should be considered in future studies to better predict patient’s individual prognosis and outcome based on their BMI.

Primary and secondary liver failure after major liver resection for perihilar cholangiocarcinoma

BackgroundThe aim of this study was to investigate the incidence and risk factors of primary and secondary liver failure after major liver resection for perihilar cholangiocarcinoma. MethodsAll patients who underwent a major liver resection for presumed perihilar cholangiocarcinoma between 2000 and 2020 at 2 tertiary-referral hospitals were included. Liver failure was defined according to the International Study Group for Liver Surgery criteria, and only grade B/C was considered clinically relevant. Primary liver failure was defined as failure without any underlying postoperative cause, and secondary liver failure was defined as liver failure with an onset after an underlying postoperative complication as a cause. ResultsThe incidence of liver failure and 90-day mortality were 20.9% and 17.0% in the 253 included patients, respectively. The incidences of primary liver failure was 9.1% and secondary liver failure was 11.9%. Abdominal sepsis, portal vein thrombosis, and arterial thrombosis were the most frequent causes. The absence of preoperative remnant liver assessment and blood loss were independent risk factors for primary liver failure. Independent risk factors for secondary liver failure were Eastern Cooperative Oncology group performance status, percutaneous biliary drainage, and preoperative cholangitis. ConclusionLiver failure after major liver resection for perihilar cholangiocarcinoma occurred in 1 of every 5 patients. The proposed subdivision into primary and secondary liver failure could help to understand differences in outcomes between centers and help to reduce liver failure.

Liver resection for perihilar cholangiocarcinoma: Impact of biliary drainage failure on postoperative outcome. Results of an Italian multicenter study

BackgroundPreoperative biliary drainage may be essential to reduce the risk of postoperative liver failure after hepatectomy for perihilar cholangiocarcinoma. However, infectious complications related to preoperative biliary drainage may increase the risk of postoperative mortality. The strategy and optimal drainage method continues to be controversial. MethodsThis is a retrospective multicenter study including patients who underwent hepatectomy for perihilar cholangiocarcinoma between 2000 and 2016 at 14 Italian referral hepatobiliary centers. The primary end point was to evaluate independent predictors for postoperative outcome in patients undergoing liver resection for perihilar cholangiocarcinoma after preoperative biliary drainage. ResultsOf the 639 enrolled patients, 441 (69.0%) underwent preoperative biliary drainage. Postoperative mortality was 8.9% (12.5% after right-side hepatectomy versus 5.7% after left-side hepatectomy; P = .003). Of the patients, 40.5% underwent preoperative biliary drainage at the first admitting hospital, before evaluation at referral centers. Use of percutaneous preoperative biliary drainage was significantly more frequent at referral centers than at community hospitals where endoscopic preoperative biliary drainage was the most frequent type. The overall failure rate after preoperative biliary drainage was 43.3%, significantly higher at community hospitals than that at referral centers (52.7% v 36.9%; P = .002). Failure of the first preoperative biliary drainage was one of the strongest predictors for postoperative complications after right-side and left-side hepatectomies and for mortality after right-side hepatectomy. Type of preoperative biliary drainage (percutaneous versus endoscopic) was not associated with significantly different risk of mortality. ConclusionFailure of preoperative biliary drainage was significantly more frequent at community hospitals and it was an independent predictor for postoperative outcome. Centers’ experience in preoperative biliary drainage management is crucial to reduce the risk of failure that is closely associated with postoperative morbidity and mortality.

Primary and secondary liver failure after major liver resection for perihilar cholangiocarcinoma

Purpose: The aim of this study was to investigate the incidence and risk factors of primary and secondary LF after major liver resection for pCCA. Method: All patients who underwent a major liver resection for suspected pCCA between 2000 and 2020 at two tertiary-referral hospitals were included. LF was defined according to the International Study Group for Liver Surgery (ISGLS) criteria and only grade B/C was considered clinically relevant. Primary LF was defined as failure without any underlying postoperative cause, and secondary as LF with an onset after an underlying postoperative complication as a cause. Results: The incidence of LF and 90-day mortality were 20.9% and 17.0% in the 253 included patients. The incidences of primary LF was 9.1% and secondary 11.9%. Abdominal sepsis, portal vein thrombosis, and arterial thrombosis were the most frequent causes. The absence of preoperative remnant liver assessment and blood loss were independent risk factors for primary LF. Independent risk factors for secondary LF were ECOG performance status, percutaneous biliary drainage, and preoperative cholangitis. Conclusion: LF after major liver resection for pCCA occurred in one of every five patients. Preoperative assessment of the remnant liver seems essential to avoid primary LF with concomitant postoperative mortality.

Total Laparoscopic Resection of Hilar Cholangiocarcinoma Type 3b: Applying a Parachute Technique for Hepaticojejunostomy

BackgroundLaparoscopic liver resection for perihilar cholangiocarcinoma (pCCA) is still in its infancy. The biliary-enteric reconstruction represents one of the most delicate parts of this minimally invasive procedure.MethodsIn this study, a 78-year old woman with perihilar cholangiocarcinoma (pCCA) type 3b underwent a hepaticojejunostomy performed by a parachute technique.ResultsThe operation, performed totally by minimally invasive resections, was completed in 386 min, with a blood loss of less than 400 ml and no transfusion requirements. Two intraluminal stents were placed during the hepaticojenunostomy for splinting of the biliary-enteric anastomosis. The patient required prolonged antibiotic treatment for postoperative cholangitis and finally was discharged on postoperative day 15. The histopathologic grading displayed a G 2–3 adenocarcinoma, pT3 pN0, M0, L1, V1, pN1, UICC IIIc R0, and the patient was referred to adjuvant chemotherapy.ConclusionResections of pCCAs, performed totally by minimally invasive techniques, may be feasible and safe for a selected group of patients. With this approach, a running-suture hepaticojejunostomy using the parachute technique represents a worthwhile strategy for biliary-enteric reconstruction.

Prognostic Relevance of the Eighth Edition of TNM Classification for Resected Perihilar Cholangiocarcinoma.

Objectives: In our study, we evaluated and compared the prognostic value and performance of the 6th, 7th, and 8th editions of the American Joint Committee on Cancer (AJCC) staging system in patients undergoing surgery for perihilar cholangiocarcinoma (PHC). Methods: Patients undergoing liver surgery with curative intention for PHC between 2002 and 2019 were identified from a prospective database. Histopathological parameters and stage of the PHC were assessed according to the 6th, 7th, and 8th editions of the tumor node metastasis (TNM) classification. The prognostic accuracy between staging systems was compared using the area under the receiver operating characteristic curve (AUC) model. Results: Data for a total of 95 patients undergoing liver resection for PHC were analyzed. The median overall survival time was 21 months (95% CI 8.1–33.9), and the three- and five-year survival rates were 46.1% and 36.2%, respectively. Staging according to the 8th edition vs. the 7th edition resulted in the reclassification of 25 patients (26.3%). The log-rank p-values for the 7th and 8th editions were highly statistically significant (p ≤ 0.01) compared to the 6th edition (p = 0.035). The AJCC 8th edition staging system showed a trend to better discrimination, with an AUC of 0.69 (95% CI: 0.52–0.84) compared to 0.61 (95% CI: 0.51–0.73) for the 7th edition. Multivariate survival analysis revealed male gender, age >65 years, positive resection margins, presence of distant metastases, poorly tumor differentiation, and lymph node involvement, such as no caudate lobe resection, as independent predictors of poor survival (p < 0.05). Conclusions: In the current study, the newly released 8th edition of AJCC staging system showed no significant benefit compared to the previous 7th edition in predicting the prognosis of patients undergoing liver resection for perihilar cholangiocarcinoma. Further research may help to improve the prognostic value of the AJCC staging system for PHC—for instance, by identifying new prognostic markers or staging criteria, which may improve that individual patient’s outcome.

Biliary Drainage Before and After Liver Resection for Perihilar Cholangiocarcinoma.

Perihilar cholangiocarcinoma (PHC) is a rare tumor that requires surgical resection for a potential cure. The role of preoperative biliary drainage has long been debated, given its treatment of biliary sepsis and decompression of the future liver remnant (FLR), but high procedure-specific morbidity. The indications, methods, and outcomes for preoperative biliary drainage are discussed to serve as a guide for perioperative management of patients with resectable PHC. Multiple studies from the literature related to perihilar cholangiocarcinoma, biliary drainage, and management of the FLR were reviewed. Commonly employed preoperative biliary drainage includes endoscopic biliary stenting and percutaneous transhepatic biliary drainage. Drainage of the FLR remains controversial, with most experts recommending drainage of the only in patients with an FLR <50%. Biliary drainage for resectable PHC requires a patient-specific approach with careful determination of the FLR and balancing of potential morbidity with the benefits of drainage.

Leakage and Stenosis of the Hepaticojejunostomy Following Surgery for Perihilar Cholangiocarcinoma.

This study aims to provide a deep insight into the incidence and clinical significance of postoperative anastomotic leakage (AL) and anastomotic stenosis (AS) of the hepaticojejunostomy (HJ) after curative-intent liver resection for perihilar cholangiocarcinoma (pCCA). Between 2011 and mid-2019, 114 patients with pCCA underwent surgery in curative intent at our institution and were analyzed regarding the postoperative incidence of AL and AS. Further, associations between AL and AS and clinical characteristics were assessed using multiple univariate logistic regression analyses. AL was diagnosed in 11.4% (13/114) of the patients resulting in postoperative mortality in the minority of patients (23.0%, 3/13). AS occurred in 11.0% (11/100) of the individuals eligible for follow-up with local tumor recurrence being the underlying pathology in 72.7% (8/11) of the cases. None of the investigated clinical factors including surgical difficulty of the HJ showed a meaningful association with AL or AS. AL and AS are frequent complications and can be treated by conservative, interventional or surgical therapy with a high success rate. Also, technical difficulty of the HJ appears not to be not associated with the occurrence of AL or AS. Moreover, AS is associated with tumor recurrence in the majority of cases.

Portal Vein Embolization is Associated with Reduced Liver Failure and Mortality in High-Risk Resections for Perihilar Cholangiocarcinoma

BackgroundPreoperative portal vein embolization (PVE) is frequently used to improve future liver remnant volume (FLRV) and to reduce the risk of liver failure after major liver resection.ObjectiveThis paper aimed to assess postoperative outcomes after PVE and resection for suspected perihilar cholangiocarcinoma (PHC) in an international, multicentric cohort.MethodsPatients undergoing resection for suspected PHC across 20 centers worldwide, from the year 2000, were included. Liver failure, biliary leakage, and hemorrhage were classified according to the respective International Study Group of Liver Surgery criteria. Using propensity scoring, two equal cohorts were generated using matching parameters, i.e. age, sex, American Society of Anesthesiologists classification, jaundice, type of biliary drainage, baseline FLRV, resection type, and portal vein resection.ResultsA total of 1667 patients were treated for suspected PHC during the study period. In 298 patients who underwent preoperative PVE, the overall incidence of liver failure and 90-day mortality was 27% and 18%, respectively, as opposed to 14% and 12%, respectively, in patients without PVE (p < 0.001 and p = 0.005). After propensity score matching, 98 patients were enrolled in each cohort, resulting in similar baseline and operative characteristics. Liver failure was lower in the PVE group (8% vs. 36%, p < 0.001), as was biliary leakage (10% vs. 35%, p < 0.01), intra-abdominal abscesses (19% vs. 34%, p = 0.01), and 90-day mortality (7% vs. 18%, p = 0.03).ConclusionPVE before major liver resection for PHC is associated with a lower incidence of liver failure, biliary leakage, abscess formation, and mortality. These results demonstrate the importance of PVE as an integral component in the surgical treatment of PHC.

Meta-analysis of the efficacy of preoperative biliary drainage in patients undergoing liver resection for perihilar cholangiocarcinoma

PurposeA systematic review was performed to evaluate the effect of preoperative biliary drainage (PBD) on outcomes after liver resection in perihilar cholangiocarcinoma (PHCC) patients. MethodMEDLINE and Web of Science were searched up to March 2019. All studies assessing morbidity, mortality, or recurrence in patients who received PBD and hepatectomy for PHCC were included. Mantel–Haenszel tests with a random-effects model were used for meta-analysis. ResultsSixteen studies involving 2162 patients were included. PBD was associated with higher major morbidity odds ratio [OR] = 1.51; 95 % confidence interval [CI] = 1.14–2.00). Selecting patients for PBD based on simple selection criteria was associated with significantly higher major morbidity (OR = 1.57; 95 % CI = 1.10–2.25). In contrast, selecting patients for PBD according to strict criteria resulted in lower major morbidity compared with patients without PBD (OR = 0.51; 95 % CI = 0.18–1.42). PBD did not influence mortality (OR = 1.06; 95 % CI = 0.70–1.61). Tumor recurrence was significantly higher in the PBD group (OR = 2.07; 95 % CI = 1.38–3.11). To decrease PBD-related complications, the duration between PBD and hepatectomy should be shorter than two weeks. Most reports described PBD on the future liver remnant side. ConclusionsRoutine PBD cannot be recommended but it may be useful in highly selected patients suffering from cholangitis, malnutrition, and long lasting jaundice, for whom an extended hepatectomy is planned. However, However, routine PBD cannot be recommended due to higher morbidity rate after hepatectomy clear patient selection criteria can be defined for PBD in future multicenter randomized controlled studies.

Risk factors of hepatic failure after liver resection for perihilar cholangiocarcinoma: Importance of future liver remnant volume, body weight ratio, and impact on long-term survival.

348 Background: Hepatic resection for perihilar cholangiocarcinoma (PHCC) is associated with high postoperative mortality. Future liver remnant volume to total liver volume ratio has been used to anticipate the risks associated with liver resection for PHCC. We sought to investigate the independent factors associated with postoperative hepatic failure (PHLF) and assess predictive value of future liver remnant volume – body weight (FLRV/Wt) ratio after resection for PHCC. Methods: This study included 287 patients who underwent major hepatectomy including caudate lobectomy with bile duct resection for PHCC between 2008 and 2015 in single center. FLRV were calculated with CT volumetry and perioperative clinical and operative data were analyzed to identify independent determinants of PHLF (grade B/C according to the International Study Group of Liver Surgery criteria) and major postoperative complications (Dindo III to IV). Results: Combined Portal vein resection was performed in 18.8%. PHLF incidence was 13.6% and 90-day mortality was 3.5%. On multivariate analysis, predictors of PHLF (p &lt; 0.05) were FLRV/Wt ratio &lt; 0.5 (odds ratio [OR] 9.45), ICG R15 &gt; 15 (OR 3.72), BMI &lt; 25.0 (OR 6.41) and R1 resection (OR 3.97). There was no significant difference of survival between two groups divided by FLRV/Wt ratio (0.5) in Kaplan-Meier analysis. There was significant difference of survival according to PHLF. In without PHLF group, 1yr, 3yr, 5yr survival were 83.1%, 45.2%, 28.1%. In PHLF B group, 1yr, 3yr, 5yr survival were 66.7%, 40.7%, 20.7% respectively. Conclusions: Insufficient FLR volume (FLRV/Wt &lt; 0.5), ICG R15 (&lt; 15), BMI (&lt; 25) and R1 resection is associated with PHLF for patients with PHCC. We confirmed that PHLF is also associated with long term outcome. Preoperative assessment to patients with PHCC should be optimized to minimize the risk of PHLF. [Table: see text]

Validation study of the post-operative mortality risk score after liver resection for perihilar cholangiocarcinoma

Validation study of the post-operative mortality risk score after liver resection for perihilar cholangiocarcinoma