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PANCREATICODUODENECTOMY WITH HILAR BILE DUCT RESECTION FOR WIDESPREAD DISTAL CHOLANGIOCARCINOMA
Ryosuke Umino
*, Minoru Esaki, Takahiro Mizui, Akinori Miyata, Satoshi Nara
National Cancer Center Hospital, Tokyo, Japan
Background: The standard surgical approach for distal cholangiocarcinoma (DCC) is pancreaticoduodenectomy (PD). Bile duct resection in PD is mainly performed at the intersection of the bile duct and right hepatic artery (RHA) or midway between the superior margin of the pancreas and the confluence of the right and left hepatic ducts (RHA level). However, DCC often extends beyond the RHA into the perihilar bile duct, leaving cancer at the bile duct margin (BDM) with standard PD. Residual invasive cancer is associated with a poor prognosis. To manage widespread DCC, PD combined with major hepatectomy, known as hepatopancreatoduodenectomy (HPD), has been proposed for radical resection. However, HPD is not easily indicated due to its high morbidity and mortality rates. PD with hilar bile duct resection (PD-hilar) may be applied to achieve R0 resection as an alternative. This study aims to evaluate the prognostic impact of PD-hilar for widespread DCC extending beyond the RHA level.
Methods: This retrospective study analyzed data from 104 patients with DCC who underwent curative-intent PD at our institution between 2005 and 2021, excluding 12 cases with portal vein resection and 3 requiring hepatic artery resection. Patients were categorized as follows: Group A (negative/carcinoma in situ (CIS) BDM with standard PD), Group B (negative/CIS with PD-hilar), and Group C (residual invasive cancer with PD-hilar). Clinicopathological characteristics, overall survival (OS) and recurrence were analyzed using Kaplan–Meier curves (log-rank test) and Cox regression.
Results: Among 104 patients, 76 (73.1%) were in Group A, 22 (21.1%) in Group B, and 6 (5.8%) in Group C, with a median follow-up of 42.3 months. Group B achieved 3-/5-year OS comparable to Group A (63.3%/44.8% vs. 65.6%/54.5%), while Group C had poorer OS (44.4%/22.2%). Although multivariate analysis identified lymph node metastasis (LNM), elevated preoperative carcinoembryonic antigen, and microscopic lymphatic invasion as independent predictors of poor prognosis. Neither invasive cancer at the BDM nor hilar bile duct resection significantly affected OS. In patients without LNM, 3-/5-year OS in Group B was 90.9%/68.2%, comparable to 78.0%/67.6% in Group A and significantly higher than 50.0%/25.0% in Group C (p=0.024). On the other hand, for those with LNM, 3-/5-year OS in Group A and B was 44.7%/32.0% and 36.4%/24.2%, respectively, comparable to Group C. Recurrence occurred in 58.7% of all patients, with no significant differences in recurrence rates and patterns between Groups A and B.
Conclusion: The indication of HPD should be cautiously determined due to its high morbidity and mortality rates. PD-hilar is not technically very difficult but effective treatment option with comparable long-term outcomes to standard PD for relatively less advanced, widespread DCC, such as without vascular invasion or LNM.
Schema and intraoperative photograph after PD-hilar
Kaplan-Meier curve of overall survival, and stratification by lymph node metastasis
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