Parenchyma-preserving hepatectomy in the surgical treatment of hilar cholangiocarcinoma.
Background: Although extended hepatic resection has been shown to improve prognosis by increasing the surgical curability rate in hilar cholangiocarcinoma, high surgical morbidity and mortality rates have been reported in patients with obstructive jaundice. Postoperative liver failure after hepatic resection in patients with obstructive jaundice has been shown to depend on the volume of the resected hepatic mass. The aim of this study was to evaluate the results of parenchyma-preserving hepatectomy in a surgical treatment for hilar cholangiocarcinoma.
Methods: Ninety-three resected patients with hilar cholangiocarcinoma were included in this retrospective study. The resected patients were stratified into three groups: the extended hepatectomy (EXH) group (n = 66), the parenchyma-preserving hepatectomy (PPH) group (n = 14), and the local resection (LR) group (n = 13). The EXH group had undergone hepatectomy more extensive than hemihepatectomy, the PPH group had undergone hepatectomy less extensive than hemihepatectomy, and the LR group had undergone extrahepatic bile duct resection without hepatic resection. Surgical curability, defined by histologically confirmed negative surgical margins, surgical morbidity and mortality, and survival rates were compared among the three groups. The clinicopathologic factors were studied for prognostic value by univariate and multivariate analyses.
Results: Surgical curability of the PPH and EXH groups was better than that of the LR group. Fifty-four percent of patients in the LR group showed positive surgical margins at the hepatic stump of the bile duct, compared with 7% in the PPH group and 20% in the EXH groups (p < 0.01 for each comparison). Surgical morbidity was higher in the EXH group (48%) than in the LR group (8%) and the PPH group (14%) (p < 0.01 and p < 0.05, respectively). Postoperative hyperbilirubinemia occurred more frequently in the EXH group (29%) than in the LR and PPH groups (0% and 0%, respectively, p < 0.05 for each comparison). Survival rates after resection were significantly higher in patients who underwent hepatectomy, including PPH and EXH, than in patients who underwent LR, 29% versus 8% at 5 years, respectively (p < 0.05). But no significant difference in survival was found between the PPH and EXH groups. Univariate and multivariate analyses showed that significant prognostic factors for survival were resected margin, lymph nodal status, and vascular resection.
Conclusions: In conclusion, PPH could obtain a curative resection and improve the outcomes for patients with hilar cholangiocarcinoma that is localized at the hepatic duct confluence who do not require vascular resection. PPH might bring about a beneficial effect in highly selected patients according to extent of cancer and high-risk patients with liver dysfunction.