Purpose: For biliary tract cancer (BTC), resection remains the only curative treatment. BTC confers a poor prognosis due to the often advanced stage at presentation. Early detection and resection may help improve overall survival. Most reports of surgical resection for BTC are limited by size. We evaluated treatment of this disease using a large national database.
Methods: The Nationwide Inpatient Sample was used to identify all patient-discharges from U.S. hospitals with the primary ICD9 diagnosis of biliary tract cancer (intrahepatic bile duct, extrahepatic bile duct, gallbladder) from 1998-2004. Patients were classified as non-resected vs. resected (hepatic resection, bile duct resection, pancreaticoduodenectomy [PD], cholecystectomy [CCY]). Primary outcome measure was in-hospital mortality. Categorical variables were analyzed by Chi square. Multivariable logistic regression was performed to identify independent predictors of resectability and operative mortality.
Results: 12,962 patient-discharges occurred for the primary diagnosis of BTC (31.9% intrahepatic ductal, 30.8% extrahepatic ductal, 30.4% gallbladder). Mean age was 69.9; 55.9% of patients were female; 74.3% were white. 28.6% underwent resection. Mean ages for those resected and not resected were 68.5 and 70.5, respectively. Overall inpatient mortality for surgical patients was 5.2%. Factors significantly associated with higher rates of operative intervention included female sex (30.8% vs. 25.8%) and treatment at teaching vs. non-teaching hospital (29.9% vs. 27.0%), and mortality was significantly increased for patients undergoing PD vs. hepatic resection (8.5% vs. 4.0%). Factors independently predictive of operative intervention included age <50 (vs. ≥70; OR 1.39, 95% CI 1.16-1.66), diagnosis of gallbladder cancer (vs. intrahepatic ductal cancer; OR 9.01, 95% CI 7.52-10.87 and vs. extrahepatic ductal cancer OR 3.66, 95% CI 3.125-4.27). Factors independently predictive of increased inpatient mortality for surgical patients included patient age ≥70 (vs. <50; OR 9.43, 95% CI 2.29-38.5) and emergent admission (vs. elective; OR 1.73, 95% CI 1.19-2.53). Presence of CHF and renal failure were also independently predictive of inpatient mortality.
Conclusions: Surgical resection for cancer of the biliary tract is associated with moderate in-patient mortality rates. Younger patients and those with the diagnosis of gallbladder cancer are most likely to undergo surgery. For those resected, younger, healthier patients have decreased inpatient mortality. Emphasis on early detection allowing the greatest chance at curative resection may improve survival for these aggressive malignancies.