Long-term outcome of extended hemihepatectomy for hilar bile duct cancer with no mortality and high survival rate

Abstract

Objective: To demonstrate our strategy for hilar bile duct cancer and to elucidate prognostic factors and the surgeon's role in long-term survival.

Summary background data: Extended hemihepatectomy is recognized as a curative treatment of hilar bile duct cancer but is not always safe because of the risk of postoperative liver failure. A safe and beneficial strategy is required.

Methods: Fifty-eight consecutive major hepatectomies for hilar bile duct cancer were reviewed retrospectively. Appropriate preoperative treatments, biliary drainage, and portal embolization were performed before major hepatectomies. The short- and long-term results of our strategy are presented and analyzed.

Results: Biliary drainage and portal embolization were performed in 39 patients (67.2%) and 31 patients (53.4%), respectively. Major hepatectomies comprised 27 extended right and 22 extended left hemihepatectomies and 9 hepatoduodenopancreatectomies. Operative morbidity and mortality rates were 43% and 0%, respectively. There was no postoperative liver failure. The overall 5-year survival rate was 40%. Univariate analysis showed that residual tumor status, lymph node involvement, and perineural invasion were associated with patients' long-term survival. A surgical margin over 5 mm resulted in better long-term survival. The delay resulting from preoperative treatment was not detrimental to long-term survival. Multivariate analysis showed that lymph node involvement was the only prognostic factor.

Conclusions: Our strategy, which includes preoperative biliary drainage and portal embolization, led to a reduction in the risks associated with major hepatectomy for hilar bile duct cancer, and resulted in zero mortality. Surgeons should aim at complete clearance of the tumor with an adequate surgical margin to ensure optimal long-term survival.

FIGURE 1. Flow chart for preoperative treatment. T.Bil, serum total bilirubin concentration; ICG R15, indocyanine green retention rate at 15 minutes.

FIGURE 2. Patient survival rate according to curability and surgical margin. In the R0 patients, the surgical margin was over 5 mm in group A, whereas the tumor was detected within 5 mm from cut surface, but not exposed, in group B. In these 4 groups, 5-year survival rates showed significant difference as a whole (P < 0.001). Five-year survival rates in groups A and B were also significantly different (group A: 81.8%; group B: 27.4%; P = 0.036), whereas there was no difference between group B of R0 and R1.

FIGURE 3. Patient survival rate according to lymph node metastasis. 5-year survival rates in pN0, pN1, and pN2 were 66.6%, 22.5%, and 9.6%, respectively, which are significantly different (P < 0.001). pN0, no lymph node metastasis; pN1, lymph node metastasis within the hepatoduodenal ligament; pN2, lymph node metastasis beyond the hepatoduodenal ligament.