Improved surgical results for hilar cholangiocarcinoma with procedures including major hepatic resection

Abstract

Objective: To evaluate the long-term outcome of aggressive surgery incorporating hepatic resection and systematic nodal dissection for advanced carcinoma involving the hepatic hilus.

Summary background data: Few long-term results are available regarding radical surgery incorporating major hepatectomy and nodal dissection.

Methods: A retrospective analysis was undertaken in 107 patients with carcinoma involving the hepatic hilus treated between 1980 and 1997. Resectional surgery was performed in 65 patients, 52 of whom underwent major hepatectomies. The effects of clinical and pathologic factors were assessed by univariate and multivariate analyses.

Results: Sixty percent of the patients with resectional surgery had stage IVA or IVB disease, and 92.3% of them underwent major hepatectomies. No in-hospital deaths were encountered in the 35 most recent resections, whereas there were six deaths in the early period. Resectional surgery was associated with a survival benefit, especially when resection margins were free from cancerous infiltration. The estimated 5-year survival rate after resection, including all deaths, was 34.8%; this was 51.6% when the margins were clear. Nodal involvement was documented in 44.6% of the resections. However, patients with metastases limited to the regional nodes showed a survival rate similar to that in patients without nodal involvement. Significant predictive factors for survival after resection were extension to the gallbladder, nodal status, resectional margins, histologic type, and gender.

Conclusions: The combination of major hepatectomy with systematic nodal dissection gave a good chance of prolonged survival for patients with carcinoma involving the hepatic hilus, even when the disease was advanced. Less-extensive procedures were also beneficial for less-advanced disease if clear resectional margins were secured.

Figure 1. Comparison of survival among patients with resection, nonresectional surgery, and nonsurgical procedures. Survival was counted from the day of admission for nonsurgical procedures and from the day of surgery in others. Significant differences were found between resection and nonresectional surgery (p < 0.0001) and between resection and no surgery (p < 0.0001).

Figure 2. Comparison of survival according to the predominant histologic type. A significant difference was found between papillary or well-differentiated tubular adenocarcinoma and the others (p = 0.0015). pap, papillary; well, well-differentiated tubular; mod, moderately differentiated tubular; poor, poorly differentiated tubular; ad-sq, adenosquamous.

Figure 3. Comparison of survival between resections with and without marginal involvement. A significant difference was found (p = 0.0018).

Figure 4. Comparison of survival according to nodal status. Significant differences were found between no involvement and beyond regional (p = 0.0211) and between regional and beyond regional (p = 0.0190).