DEFINING THE OPTIMAL BILIRUBIN LEVEL BEFORE HEPATECTOMY FOR HILAR CHOLANGIOCARCINOMA
Wong-Hoi She*, Tan To Cheung, Ka Wing Ma, Wing Chiu Dai, Albert Chan, Kenneth S. Chok, Chung Mau Lo
Surgery, The University of Hong Kong, Hong Kong, Hong Kong
Purpose: To identify the pre-hepatectomy bilirubin level in hilar cholangiocarcinoma (HC) patients that would affect postoperative morbidity and mortality.
Methods: Data of patients having hepatectomy for HC were analyzed. Preoperative bilirubin level was derived from Youden's index and logistic regression that would make a survival difference. The identified level was used as the cutoff to divide patients into two groups. The groups were compared.
Results: Ninety patients received hepatectomy for HC. Their median preoperative bilirubin level was 23μMol/L. A cutoff preoperative bilirubin level of 74.5μMol/L was derived from Youden's index (sensitivity 0.333; specificity 0.949) and confirmed optimal in logistic regression (relative risk 9.250; 95% CI 1.932-44.291; p=0.005), and mortality was shown to be statistically different at 90 days (p=0.008). Patients were divided into Groups A (≤75μMol/L; n=82) and B (>75μMol/L; n=8). Group B had significantly higher bilirubin level (p<0.001), more transfusions (100% vs 42.0%; p=0.011), more blood loss (3.12 vs 1.4L; p=0.008) and replacement (2.45 vs 0.0L; p<0.001), more renal complications (p=0.036), more in-hospital deaths (50% vs 8.5%; p=0.004), and more 90-day deaths (50% vs 9.8%; p=0.008). Group A had significantly longer follow-up (p=0.008). The groups were otherwise comparable. Disease-free survival was similar in the groups (p=0.142) but overall survival was significantly better in Group A (5-year, 25.2% vs 0%; p<0.001). On multivariate analysis, blood replacement and bilirubin level were independent prognostic factors for survival.
Conclusions: Operating HC patients with hyperbilirubinemia would result in more intraoperative blood loss and transfusion. A preoperative bilirubin level <75μMol/L is suggested for better surgical outcomes.
Overall survival comparison in patients undergoing hepatectomy for hilar cholangiocarcinoma using bilirubin 75 μmol/L as cut off
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