Top

Published in:

01-02-2010 | Original Article

Surgical Management of Infrahilar/Suprapancreatic Cholangiocarcinoma: an Analysis of the Surgical Procedures, Surgical Margins, and Survivals of 77 Patients

Authors: Yoshihiro Sakamoto, Kazuaki Shimada, Satoshi Nara, Minoru Esaki, Hidenori Ojima, Tsuyoshi Sano, Junji Yamamoto, Tomoo Kosuge

Published in: Journal of Gastrointestinal Surgery | Issue 2/2010

Abstract

Background

Optical surgical management of infrahilar/suprapancreatic cholangiocarcinoma remains controversial.

Methods

Between 1988 and 2006, 77 patients with infrahilar/suprapancreatic cholangiocarcinoma underwent curative surgical resections following our intention-to-treat strategy. The clinicopathological factors affecting survival were evaluated using univariate and multivariate analyses with regard to the surgical procedures and surgical margins.

Results

The surgical procedure included extrahepatic bile duct resection alone (EHBD; n = 17), major hepatectomy combined with extrahepatic bile duct resection (MHx; n = 26), pancreaticoduodenectomy (PD; n = 28), and MHx and concomitant PD (HPD; n = 6). Performance of MHx and/or PD in addition to EHBD increased surgical morbidity (p = 0.001). Among patients undergoing the four surgical procedures (EHBD, MHx, PD, and HPD), no significant difference was found in the incidence of positive overall surgical margins (53%, 65%, 46%, and 67%, p = 0.51) or long-term survivals (median survival time, 51, 27, 41, and 22 months, p = 0.60). A multivariate analysis revealed that perineural invasion (95% confidence interval, 1.1–12.3, p = 0.009), nodal metastasis (1.6–6.8, p = 0.001), and blood transfusion (1.1–3.9, p = 0.02) were independent predictors of a poor outcome. Perineural invasion was associated with positive radial margins (p = 0.045) and submucosal ductal infiltration (p = 0.03).

Conclusion

Perineural invasion, rather than the type of surgical procedure, had a significant impact on surgical curability and survival of patients with infrahilar/suprapancreatic cholangiocarcinoma treated according to our intention-to-treat strategy.

Kosuge T, Yamamoto J, Shimada K, Yamasaki S, Makuuchi M. Improved surgical results for hilar cholangiocarcinoma with procedures including major hepatic resection. Ann Surg 1999;230:663–671.CrossRefPubMed

Neuhaus P, Jonas S, Bechstein WO, Lohmann R, Radke C, Kling N, Wex C, Lobeck H, Hintze R. Extended resections for hilar cholangiocarcinoma. Ann Surg 1999;230:808–818.CrossRefPubMed

Kawasaki S, Imamura H, Kobayashi A, Noike T, Miwa S, Miyagawa S. Results of surgical resection for patients with hilar bile duct cancer. Application of extended hepatectomy after biliary drainage and hemihepatic portal vein embolization. Ann Surg 2003;238:84–92.CrossRefPubMed

Seyama Y, Kubota K, Sano K, Noie T, Takayama T, Kosuge T, Makuuchi M. Long-term outcome of extended hemihepatectomy for hilar bile duct cancer with no mortality and high survival rate. Ann Surg 2003;238:73–83.CrossRefPubMed

Kondo S, Hirano S, Ambo Y, Tanaka E, Okushiba S, Morikawa T, Katoh H. Forty consecutive resection of hilar cholangiocarcinoma with no postoperative mortality and no positive ductal margins. Results of a prospective study. Ann Surg 2004;240:95–101.CrossRefPubMed

Hemming AW, Reed AI, Fujita S, Foley DP, Howard RJ. Surgical management of hilar cholangiocarcinoma. Ann Surg 2005;241:693–702.CrossRefPubMed

Sano T, Shimada K, Sakamoto Y, Yamamoto J, Yamasaki S, Kosuge T. One hundred two consecutive hepatobiliary resections for perihilar cholangiocarcinoma with zero mortality. Ann Surg 2006;244:240–247.CrossRefPubMed

Bhuiya MR, Nimura Y, Kamiya J, Kondo S, Nagino M, Hayakawa N. Clinicopathologic factors influencing survival of patients with bile duct carcinoma: multivariate statistical analysis. World J Surg 1993;17:653–657.CrossRefPubMed

Ogura Y, Takahashi K, Tabata M, Mizumoto R. Clinicopathological study on carcinoma of the extrahepatic bile duct with special focus on cancer invasion on the surgical margins. World J Surg 1994;18:778–784.CrossRefPubMed

10.

Fong Y, Blumgart LH, Lin E, Fortner JG, Brennan MF. Outcome of treatment for distal bile duct cancer. Br J Surg 1996;83:1712–1715.CrossRefPubMed

11.

Kayahara M, Nagakawa T, Ohta T, Kitagawa H, Tajima H, Miwa K. Role of nodal involvement and the periductal soft-tissue margin in middle and distal bile duct cancer. Ann Surg 1999;229:76–83.CrossRefPubMed

12.

Sasaki R, Takahashi M, Funato O, Nitta H, Murakami M, Kawamura H, Suto T, Kanno S, Saito K. Prognostic significance of lymph node involvement in middle and distal bile duct cancer. Surgery 2001;129:677–683.CrossRefPubMed

13.

Todoroki T, Kawamoto T, Koike N, Fukao K, Shoda J, Takahashi H. Treatment strategy for patients with middle and lower third bile duct cancer. Br J Surg 2001;88:364–370.CrossRefPubMed

14.

Yoshida T, Matsumoto T, Sasaki A, Morii Y, Aramaki M, Kitano S. Prognostic factors after pancreatoduodenectomy with extended lymphadenectomy for distal bile duct cancer. Arch Surg 2002;137:69–73.CrossRefPubMed

15.

Sakamoto Y, Kosuge T, Shimada K, Sano T, Ojima H, Yamamoto J, Yamasaki S, Takayama T, Makuuchi M. Prognostic factors of surgical resection in middle and distal bile duct cancer—an analysis of 55 patients concerning the significance of ductal and excisional margins. Surgery 2005;137:396–402.CrossRefPubMed

16.

Japanese Society of Biliary Surgery (JSBC). General Rules for Surgical and Pathological Studies on Cancer of the Biliary Tract. 5th ed. Tokyo: Kanehara, 2003.

17.

Bismuth H, Corlette MB. Intrahepatic cholangioenteric anastomosis in carcinoma of the hilus of the liver. Surg Gynecol Obstet 1975;140:170–178.PubMed

18.

Tompkins RK, Saunders K, Roslyn JJ, Longmire WP Jr. Changing patterns in diagnosis and management of bile duct cancer. Ann Surg 1990;211:614–620.PubMed

19.

Reding R, Buard JL, Lebeau G, Launois B. Surgical management of 552 carcinomas of the extrahepatic bile ducts (gallbladder and periampullary tumors excluded). Results of the French surgical association survey. Ann Surg 1991;213:236–241.CrossRefPubMed

20.

Sakamoto E, Nimura Y, Hayakawa N, Kamiya J, Kondo S, Nagino M, Kanai M, Miyachi M, Uesaka K. The pattern of infiltration at the proximal border of hilar bile duct carcinoma. Ann Surg 1998;227:405–411.CrossRefPubMed

21.

Ikeyama T, Nagino M, Oda K, Ebata T, Nishio H, Nimura Y. Surgical approach to Bismuth type I and II hilar cholangiocarcinomas: audit of 54 consecutive cases. Ann Surg 2007;246:1052–1057.CrossRefPubMed

22.

Ito F, Agni R, Rettammel RJ, Been MJ, Cho CS, Mahvi DM, Rikkers LF, Weber SM. Resection of hilar cholangiocarcinoma: concomitant liver resection decreases hepatic recurrence. Ann Surg 2008;248:273–279.CrossRefPubMed

23.

Sakamoto Y, Sano T, Shimada K, Kosuge T, Kimata Y, Sakuraba M, Yamamoto J, Ojima H. Clinical significance of reconstruction of the right hepatic artery for biliary malignancy. Langenbecks Arch Surg 2006;391:203–208.CrossRefPubMed

24.

Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Buchler M. International study group on pancreatic fistula definition. International study group on pancreatic fistula definition. Postoperative pancreatic fistula: an International Study Group (ISGPF) definition. Surgery 2005;138:8–13.CrossRefPubMed

25.

Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Traverso LW, Yeo CJ, Büchler MW. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2007;142:761–768.CrossRefPubMed

26.

International Union Against Cancer (UICC). TNM classification of malignant tumours. In Sobin LH, Wittekind CH, eds. 6th ed. New York: Wiley-Liss, 2002.

27.

Bhuiya MR, Nimura Y, Kamiya J, Kondo S, Fukata S, Hayakawa N, Shionoya S. Clinicopathologic studies on perineural invasion of bile duct carcinoma. Ann Surg 1992;215:344–349.PubMedCrossRef

28.

Yamaguchi R, Nagino M, Oda K, Kamiya J, Uesaka K, Nimura Y. Perineural invasion has a negative impact on survival of patients with gallbladder carcinoma. Br J Surg 2002;89:1130–1136.CrossRefPubMed

29.

Sakamoto Y, Kosuge T, Shimada K, Sano T, Hibi T, Yamamoto J, Takayama T, Makuuchi M. Clinical significance of extrahepatic bile duct resection for advanced gallbladder cancer. J Surg Oncol 2006;94:298–306.CrossRefPubMed

30.

Makuuchi M, Thai BL, Takayasu K, Takayama T, Kosuge T, Gunvén P, Yamazaki S, Hasegawa H, Ozaki H. Preoperative portal embolization to increase safety of major hepatectomy for hilar bile duct carcinoma: a preliminary report. Surgery 1990;107:521–527.PubMed

31.

Seyama Y, Kubota K, Kobayashi T, Hirata Y, Itoh A, Makuuchi M. Two-staged pancreatoduodenectomy with external drainage of pancreatic juice and omental graft technique. J Am Coll Surg 1998;187:103–105.CrossRefPubMed

32.

Sakamoto Y, Shimada K, Esaki M, Kajiwara T, Sano T, Kosuge T. Wrapping the stump of the gastroduodenal artery using the falciform ligament during pancreaticoduodenectomy. J Am Coll Surg 2007;204:334–336.CrossRefPubMed

33.

Foster RS Jr, Costanza MC, Foster JC, Wanner MC, Foster CB. Adverse relationship between blood transfusions and survival after colectomy for colon cancer. Cancer. 1985;55:1195–1201.CrossRefPubMed

34.

Nowak MM, Ponsky JL. Blood transfusion and disease-free survival in carcinoma of the breast. J Surg Oncol 1984;27:124–130.CrossRefPubMed

35.

Sugezawa A, Kaibara N, Sumi K, Ohta M, Kimura O, Nishidoi H, Koga S. Blood transfusion and the prognosis of patients with gastric cancer. J Surg Oncol. 1989;42:113–116.CrossRefPubMed

36.

Park SJ, Kim SW, Jang JY, Lee KU, Park YH. Intraoperative transfusion: is it a real prognostic factor of periampullary cancer following pancreatoduodenectomy? World J Surg 2002;26:487–492.CrossRefPubMed

37.

Yamamoto J, Kosuge T, Takayama T, Shimada K, Yamasaki S, Ozaki H, Yamaguchi N, Mizuno S, Makuuchi M. Perioperative blood transfusion promotes recurrence of hepatocellular carcinoma after hepatectomy. Surgery 1994;115:303–309.PubMed

38.

Blajchman MA, Bardossy L, Carmen R, Sastry A, Singal DP. Allogeneic blood transfusion-induced enhancement of tumor growth: two animal models showing amelioration by leukodepletion and passive transfer using spleen cells. Blood 1993;81:1880–1882.PubMed

Title: Surgical Management of Infrahilar/Suprapancreatic Cholangiocarcinoma: an Analysis of the Surgical Procedures, Surgical Margins, and Survivals of 77 Patients
Authors: Yoshihiro Sakamoto
Kazuaki Shimada
Satoshi Nara
Minoru Esaki
Hidenori Ojima
Tsuyoshi Sano
Junji Yamamoto
Tomoo Kosuge
Publication date: 01-02-2010
Publisher: Springer-Verlag
Published in: Journal of Gastrointestinal Surgery / Issue 2/2010
Print ISSN: 1091-255X
Electronic ISSN: 1873-4626
DOI: https://doi.org/10.1007/s11605-009-1072-7

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Surgical Management of Infrahilar/Suprapancreatic Cholangiocarcinoma: an Analysis of the Surgical Procedures, Surgical Margins, and Survivals of 77 Patients

Abstract

Background

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 2/2010

Clinicopathologic Analysis of Ampullary Neoplasms in 450 Patients: Implications for Surgical Strategy and Long-Term Prognosis

Primary Omental Mesothelioma: A Rare but Important Differential Diagnosis in Previous Asbestos Exposure

Eleven Cases of Postoperative Hepatic Infarction Following Pancreato-Biliary Surgery

Surgery for Obstructed Colorectal Malignancy in an Asian Population: Predictors of Morbidity and Comparison Between Left- and Right-Sided Cancers

GIST with a Twist—Upregulation of PDGF-B Resulting in Metachronous Gastrointestinal Stromal Tumor and Dermatofibrosarcoma Protuberans

Beyond Epithelial to Mesenchymal Transition: A Novel Role for the Transcription Factor Snail in Inflammation and Wound Healing