Hepatopancreatoduodenectomy for advanced biliary malignancies

Abstract

Background: Hepatopancreatoduodenectomy (HPD) has been considered the only curative treatment for metastatic cholangiocarcinoma and some locally advanced gallbladder cancers (GBCs). However, HPD has not yet been included in treatment guidelines as a standard surgical procedure in consideration of its morbidity and mortality rates. The aim of this study was to evaluate the safety and effectiveness of HPD in treating biliary malignancies.

Methods: The medical records of 57 patients with advanced biliary cancer undergoing HPD from January 2009 to December 2019 were retrospectively retrieved. A case-control analysis was conducted at our department. Patients with advanced GBC who underwent HPD (HPD-GBC group) were compared with a control group (None-HPD-GBC group). Baseline characteristics, preoperative treatments, tumor pathologic features, operative results, and prognosis were assessed.

Results: Thirteen patients with cholangiocarcinoma and 44 patients with GBC underwent HPD at our department. Significant postoperative complications (grade III or greater) and postoperative pancreatic fistula were observed in 24 (42.1%) and 15 (26.3%) patients, respectively. One postoperative death occurred in the present study. Overall survival (OS) was longer in patients with advanced cholangiocarcinoma than in those with GBC (median survival time [MST], 31 months vs . 11 months; P < 0.001). In the subgroup analysis of patients with advanced GBC, multivariate analysis demonstrated that T4 stage tumors ( P = 0.012), N2 tumors ( P = 0.001), and positive margin status ( P = 0.004) were independently associated with poorer OS. Patients with either one or more prognostic factors exhibited a shorter MST than patients without those prognostic factors ( P < 0.001).

Conclusion: HPD could be performed with a relatively low mortality rate and an acceptable morbidity rate in an experienced high- volume center. For patients with advanced GBC without an N2 or T4 tumor, HPD can be a preferable treatment option.

Figure 1

Intraoperative image and diagram demonstrating en bloc resection of segment 4a + 5 and PD. (A) Kocher's maneuver was applied to the lift head of the pancreas and the duodenum, and a biopsy of the periaortic lymph node was routinely performed. (B) PD: after transecting the gastric antrum, the pancreas, and the jejunum, the small blood vessels between the uncinate process and the SMA were separated and ligated until its root. The red solid line indicates the transection of the gastric antrum. The yellow dotted line indicates the transection of the pancreas at the neck. (C) Resection of segment 4a + 5. (D) After the completion of segment 4a + 5 resection and PD. CHA: Common hepatic artery; CHD: Common hepatic duct; IVC: Inferior vena cava; LRV: Left renal vein; PD: Pancreatoduo-denectomy; PV: Portal vein; SMA: Superior mesenteric artery.

Figure 2

(A) Kaplan–Meier analysis showed a significant difference in OS between the GBC group and the cholangiocarcinoma group (P < 0.001). (B) Kaplan–Meier analysis showed a significant difference in GBC patients with or without prognostic factors (P < 0.001, HR, 95% CI [3.431, 1.853–6.355]). CI: Confidence interval; GBC: Gallbladder cancer; OS: Overall survival.

Figure 3

Kaplan–Meier analysis showed the overall median survival in the HPD-GBC and None-HPD-GBC groups was 11 months and 12.12 months, respectively (P > 0.05).