Preoperative Cholangitis and Future Liver Remnant Volume Determine the Risk of Liver Failure in Patients Undergoing Resection for Hilar Cholangiocarcinoma

Abstract

Background The highest mortality rates after liver surgery are reported in patients who undergo resection for hilar cholangiocarcinoma (HCCA). In these patients, postoperative death usually follows the development of hepatic insufficiency. We sought to determine the factors associated with postoperative hepatic insufficiency and death due to liver failure in patients undergoing hepatectomy for HCCA. Study Design This study included all consecutive patients who underwent hepatectomy with curative intent for HCCA at two centers from 1996 through 2013. Preoperative clinical and operative data were analyzed to identify independent determinants of i) hepatic insufficiency and ii) liver failure–related death. Results The study included 133 patients with right or left major (n=67) or extended (n=66) hepatectomy. Preoperative biliary drainage was performed in 98 patients and was complicated by cholangitis in 40 cases. In all these patients, cholangitis was controlled before surgery. Major (Dindo III-IV) postoperative complications occurred in 73 patients (55%), with 29 suffering from hepatic insufficiency. Fifteen patients (11%) died within 90 days after surgery, 10 of them of liver failure. On multivariate analysis, predictors of postoperative hepatic insufficiency (all p<0.05) were preoperative cholangitis (odds ratio [OR]=3.2), future liver remnant (FLR) volume <30% (OR=3.5), preoperative total bilirubin level >3 mg/dl (OR=4), and albumin level <3.5 mg/dl (OR=3.3). Only preoperative cholangitis (OR=7.5, p=.016) and FLR volume <30% (OR=7.2, p=.019) predicted postoperative liver failure–related death. Conclusions Preoperative cholangitis and insufficient FLR volume are major determinants of hepatic insufficiency and postoperative liver failure–related death. Given the association between biliary drainage and cholangitis, the preoperative approach to patients with HCCA should be optimized to minimize the risk of cholangitis.

Preoperative biliary drainage versus direct surgery for perihilar cholangiocarcinoma: A retrospective study at a single center

“…The current results indicated that the short-term surgical and postoperative outcomes of the group that directly underwent surgery were comparable to those of the group that underwent PBD. This finding is consistent with the results of previous studies and meta-analyses (12)(13)(14). Several studies have found that PBD increased the risk of postoperative complications and infections (15)(16)(17), but our data did not demonstrate this.…”

Albumin-Indocyanine Green Evaluation Grading System Predicts Post-Hepatectomy Liver Failure for Biliary Tract Cancer

“…Liver resection for biliary tract cancer is reported to be associated with high rates of morbidity (22–55%) and mortality (3.3–11%), even at high-volume centers [5, 11, 12]. PHLF is the most common cause of postoperative death.…”

Compliance with evidence‐based multidisciplinary guidelines on perihilar cholangiocarcinoma

“…Previous studies have also shown a clear correlation between drainage-induced cholangitis and mortality after resection and between drainage failure and survival in the palliative setting. 7,10,20 The overall relatively high therapeutic failure rate and inadequate drainage of the FLR in the study period resulted in exposure of patients to multiple drainage procedures and, consequently, to unnecessary risks of complications. The observation that the complication risks of biliary drainage were comparably as high in the regional hospitals as in experienced hands in our center, underscores the complex nature of drainage in hilar obstructions.…”

“…Patients had a median age of 66 years, included 104 males (65.8%) and presented with jaundice in the majority of cases (75.9%). Median time interval between first suspicion of PHC at the regional center and referral to our MDT was 11 days (IQR: [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]. In 39 of 158 cases (24.7%), the time to referral was 21 days or more.…”