Results of surgical resection for patients with hilar bile duct cancer: application of extended hepatectomy after biliary drainage and hemihepatic portal vein embolization

Abstract

Objective: To evaluate the feasibility of an aggressive surgical approach incorporating major hepatic resection after biliary drainage and preoperative portal vein embolization for patients with hilar bile duct cancer.

Summary background data: Although many surgeons have emphasized the importance of major hepatectomy in terms of curative resection for patients with hilar bile duct cancer, this procedure results in a high incidence of postoperative morbidity and mortality in patients with cholestasis-induced impaired liver function.

Methods: A retrospective cohort study was conducted in 140 patients with hilar bile duct cancer treated from 1990 through 2001. Resectional surgery was performed in 79 patients, 69 of whom underwent major hepatic resection. Thirteen patients underwent concomitant pancreaticoduodenectomy. Preoperative biliary drainage was carried out in all 65 patients who had obstructive jaundice. Portal vein embolization was conducted in 41 of 51 patients undergoing extended right hepatectomy. Short- and long-term outcomes were evaluated.

Results: No patient experienced postoperative liver failure (maximum total bilirubin level, 5.4 mg/dL). The in-hospital mortality rate was 1.3% (1 in 79, resulting from cerebral infarction). A histologically negative resection margin was obtained more frequently when the scheduled extended hepatic resection was conducted (75% vs 44%, P = 0.0178). The estimated 5-year survival rate was 40% when histologically negative resection margins were obtained, but only 6% if the margins were positive. Multivariate analysis identified the resection margin and nodal status as independent factors predictive of survival.

Conclusions: Extensive resection, mainly extended right hemihepatectomy, after biliary drainage and preoperative portal vein embolization, when necessary, for patients with hilar bile duct cancer can be performed safely and is more likely to result in histologically negative margins than other resection methods.

FIGURE 1. Flow diagram of 140 patients admitted to our institute. The group of patients who underwent potentially curative operations includes those in whom the resection margin was revealed to be histologically positive (R1 resection). PVE, preoperative portal vein embolization.

FIGURE 2. Patient survival stratified according to the resection margin status. The solid line indicates survival of patients with histologically negative margins (n = 54; median survival, 37.4 mo; 1-, 3-, and 5-y survival rates = 90.4%, 52.0%, and 39.9%, respectively). The dotted line indicates survival of patients with histologically positive margins (n = 25; median survival, 26.3 mo; 1-, 3-, and 5-y survival rates = 87.1%, 24.2%, and 6.0%, respectively). Survival was significantly longer in patients with negative than positive margins (P = 0.0099).

FIGURE 3. Patient survival stratified according to the lymph node involvement status. The solid line indicates survival of patients without lymph node involvement (n = 43; median survival, 53.7 mo; 1-, 3-, and 5-y survival rates = 95.1%, 64.7%, and 42.4%, respectively). The dotted line indicates survival of patients with lymph node involvement (n = 35; median survival, 23.5 mo; 1-, 3-, and 5-y survival rates = 82.4%, 22.2%, and 15.9%, respectively). Survival was significantly longer in patients without than with lymph node involvement (P = 0.0001).