Is radical resection of hilar cholangiocarcinoma plus partial resection of pancreatic head justified for advanced hilar cholangiocarcinoma?

Abstract

Background To outline our experience with the radical resection of hilar cholangiocarcinoma (HCCA) combined with the partial resection of the pancreatic head (RRHCCAPRPH) as a treatment for HCCA with distal bile duct involvement and to appraise the feasibility of this challenging procedure. Methods Between 2007 and 2017, 205 patients with HCCA who underwent curative surgery at our hospital were included. Among the patients, extrahepatic bile duct resection combined with hepatectomy (EBDRH), RRHCCAPRPH and hepatopancreaticoduodenectomy (HPD) was performed in 168, 21 and 16 patients, respectively. Clinical pathological factors, post‐operative complications and survival were compared between the three groups. Results There was a significant difference in operative blood loss, operative time, post‐operative hospital stay and tumour size between EBDRH group, RRHCCAPRPH group and HPD group (P < 0.05). In terms of post‐operative complications, there was no statistical difference between the three groups (P = 0.177). Further analysis showed that the incidence of pancreatic fistula (43.8%) and delayed gastric emptying (25%) after HPD were significantly higher than the other two groups. The median survival time and overall survival rate for 172 patients with R0 resection were 33 months and 85.5% at 1 year, 47.7% at 3 years, 28.4% at 5 years. Furthermore, the 1‐, 3‐ and 5‐year survival rates of patients with EBDRH, RRHCCAPRPH and HPD after R0 resection were 86.2%, 48.7%, 29.2%; 85.0%, 44.0%, 24.7% and 78.6%, 42.9%, 22.9%, respectively (P = 0.948). Conclusion The RRHCCAPRPH in some selected patients can actually replace HPD as a surgical treatment for HCCA with distal bile duct involvement.

Current role of hepatopancreatoduodenectomy for the management of gallbladder cancer and extrahepatic cholangiocarcinoma: A systematic review

“…The effects of the biliary stasis on the liver remnant include impaired function of hepatocyte mitochondria, impaired activity of microsomial mixed function oxidase, and in general increased predisposition to endotoxemia[ 5 , 29 ]. The role of preoperative biliary drainage of jaundiced patients scheduled for PD remains questioned[ 11 ]. However, authors suggested that biliary drainage may be appropriate before HPD, especially when major hepatectomy is planned[ 10 , 11 , 30 , 31 ].…”

“…The role of preoperative biliary drainage of jaundiced patients scheduled for PD remains questioned[ 11 ]. However, authors suggested that biliary drainage may be appropriate before HPD, especially when major hepatectomy is planned[ 10 , 11 , 30 , 31 ].…”

“…Other possible complications, which can originate from the combination of hepatic resection and PD were delayed gastric emptying, hemorrhage, multi-organ failure, liver abscess, suppurative cholangitis, peritonitis, metabolic acidosis, portal vein thrombosis, sepsis, and hepaticojejunostomy leakage[ 5 , 8 - 10 , 20 ]. Some authors have proposed technical variants like ‘pancreatic sparing resection’ during HPD with the aim to reduce mortality and morbidity linked to HPD[ 11 , 20 ], but no conclusions can be drawn at this stage due to the paucity of reports.…”

“…While patients with GC and ECC have in general a poor prognosis, long survival outcomes can be achieved in selected patients with R0 resection, since it has been demonstrated that negative margin is the most prognostic factor influencing long term survival after resection[ 11 ]. HPD carried out with curative intent with free margins has been reported to obtain acceptable survival outcomes, although important differences exist between GC and ECC, having the former a worst prognosis.…”

“…Since the results of those procedures had been published essentially in Japanese journals, HPD had for years limited diffusion in the rest of the world[ 2 ]. It was not until the start of the 2000's that limited patient series on the use of that procedure were published also from American, European, and Asian institutions other than Japanese ones[ 8 - 11 ]. Looking at review articles, two main papers reported on the results of HPD published until the year 2015[ 1 , 5 ].…”