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. 2016 Aug;223(2):321-331.e1.
doi: 10.1016/j.jamcollsurg.2016.03.035. Epub 2016 Apr 5.

Postoperative Mortality after Liver Resection for Perihilar Cholangiocarcinoma: Development of a Risk Score and Importance of Biliary Drainage of the Future Liver Remnant

Jimme K Wiggers  1 , Bas Groot Koerkamp  2 , Kasia P Cieslak  1 , Alexandre Doussot  3 , David van Klaveren  4 , Peter J Allen  3 , Marc G Besselink  1 , Olivier R Busch  1 , Michael I D'Angelica  3 , Ronald P DeMatteo  3 , Dirk J Gouma  1 , T Peter Kingham  3 , Thomas M van Gulik  1 , William R Jarnagin  5
Affiliations

Postoperative Mortality after Liver Resection for Perihilar Cholangiocarcinoma: Development of a Risk Score and Importance of Biliary Drainage of the Future Liver Remnant

Jimme K Wiggers et al. J Am Coll Surg. 2016 Aug.

Abstract

Background: Liver surgery for perihilar cholangiocarcinoma (PHC) is associated with postoperative mortality ranging from 5% to 18%. The aim of this study was to develop a preoperative risk score for postoperative mortality after liver resection for PHC, and to assess the effect of biliary drainage of the future liver remnant (FLR).

Study design: A consecutive series of 287 patients submitted to major liver resection for presumed PHC between 1997 and 2014 at 2 Western centers was analyzed; 228 patients (79%) underwent preoperative drainage for jaundice. Future liver remnant volumes were calculated with CT volumetry and completeness of FLR drainage was assessed on imaging. Logistic regression was used to develop a mortality risk score.

Results: Postoperative mortality at 90 days was 14% and was independently predicted by age (odds ratio [OR] per 10 years = 2.1), preoperative cholangitis (OR = 4.1), FLR volume <30% (OR = 2.9), portal vein reconstruction (OR = 2.3), and incomplete FLR drainage in patients with FLR volume <50% (OR = 2.8). The risk score showed good discrimination (area under the curve = 0.75 after bootstrap validation) and ranking patients in tertiles identified 3 (ie low, intermediate, and high) risk subgroups with predicted mortalities of 2%, 11%, and 37%. No postoperative mortality was observed in 33 undrained patients with FLR volumes >50%, including 10 jaundiced patients (median bilirubin level 11 mg/dL).

Conclusions: The mortality risk score for patients with resectable PHC can be used for patient counseling and identification of modifiable risk factors, which include FLR volume, FLR drainage status, and preoperative cholangitis. We found no evidence to support preoperative biliary drainage in patients with an FLR volume >50%.

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Figures

Figure 1
Figure 1
FLR volumes and associated outcomes in the patient cohort. (A) Distribution of FLR volumes among patients who underwent a right- or left-sided liver resection, and (B) 90-day mortality and liver failure rates according to the FLR volumes.
Figure 1
Figure 1
FLR volumes and associated outcomes in the patient cohort. (A) Distribution of FLR volumes among patients who underwent a right- or left-sided liver resection, and (B) 90-day mortality and liver failure rates according to the FLR volumes.
Figure 2
Figure 2
Breakdown of postoperative mortality according to FLR volume, showing incomplete FLR drainage as an adverse risk factor in patients with a small or intermediate FLR, but not in patients with a large FLR. Preoperative drainage was used in 100% and 97.1% in the small FLR group; in 90.5% and 78.2% in the intermediate FLR group; in 75.0% and 72.6% in the large FLR group (enumerating patients with incomplete and complete FLR drainage, respectively). FLR Future liver remnant; 90d mortality postoperative 90-day mortality.
Figure 3
Figure 3
Breakdown of 115 patients with a large FLR (>50%) showing the effect of biliary drainage on cholangitis and associated mortality. FLR Future liver remnant; 90d mortality postoperative 90-day mortality.
See this image and copyright information in PMC

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