Multicentre European study of preoperative biliary drainage for hilar cholangiocarcinoma
ABSTRACT BACKGROUND: Indications for preoperative biliary drainage (PBD) in the context of hepatectomy for hilar malignancies are still debated. The aim of this study was to investigate current European practice regarding biliary drainage before hepatectomy for Klatskin tumours. METHODS: This was a retrospective analysis of all patients who underwent formal or extended right or left hepatectomy for hilar cholangiocarcinoma between 1997 and 2008 at 11 European teaching hospitals, and for whom details of serum bilirubin levels at admission and at the time of surgery were available. PBD was performed at the physicians' discretion. The primary outcome was 90-day mortality. Secondary outcomes were morbidity and cause of death. The association of PBD and of preoperative serum bilirubin levels with postoperative mortality was assessed by logistic regression, in the entire population as well as separately in the right- and left-sided hepatectomy groups, and was adjusted for confounding factors. RESULTS: A total of 366 patients were enrolled; PBD was performed in 180 patients. The overall mortality rate was 10·7 per cent and was higher after right- than left-sided hepatectomy (14·7 versus 6·6 per cent; adjusted odds ratio (OR) 3·16, 95 per cent confidence interval 1·50 to 6·65; P = 0·001). PBD did not affect overall postoperative mortality, but was associated with a decreased mortality rate after right hepatectomy (adjusted OR 0·29, 0·11 to 0·77; P = 0·013) and an increased mortality rate after left hepatectomy (adjusted OR 4·06, 1·01 to 16·30; P = 0·035). A preoperative serum bilirubin level greater than 50 µmol/l was also associated with increased mortality, but only after right hepatectomy (adjusted OR 7·02, 1·73 to 28·52; P = 0·002). CONCLUSION: PBD does not affect overall mortality in jaundiced patients with hilar cholangiocarcinoma, but there may be a difference between patients undergoing right-sided versus left-sided hepatectomy. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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ABSTRACT: Cholangiocarcinomas (CCAs) are rare malignancies that originate from the epithelial cells of the bile ducts. It is the second most-common primary liver cancer after hepatocellular carcinoma. Recent epidemiologic studies have shown that the overall incidence and mortality rates of CCAs are increasing. Diagnosis is often challenging due to the difficulty in getting tissue/cytology for confirmation, and it comprises a combination of cross-imaging, tumor markers, histology, and cholangiography. Surgery involving major resections of liver, bile duct, pancreas, and at times adjacent vessels is the only chance for cure. Evaluation should be focused on the assessment of tumor resectability, hepatic reserve, and patient physiological fitness for major surgery. In patients not fit for major surgery, biliary drainage for jaundice is an appropriate intervention and if there is histologic confirmation of a CCA, palliative therapies focused on local and systemic disease control should be considered. The endeavor to expand the indications for liver transplantation reflects the efforts to provide an effective form of therapy for a previously untreatable disease. A multidisciplinary specialized approach should be the platform for providing the best comprehensive care for these patients.Seminars in Liver Disease 08/2013; 33(3):248-61. DOI:10.1055/s-0033-1351784 · 5.12 Impact Factor
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ABSTRACT: Extended hepatectomy, or liver transplantation of reduced-size graft, can lead to a pattern of clinical manifestations, namely "post-hepatectomy liver failure" and "small-for-size syndrome" respectively, that can range from mild cholestasis to irreversible organ non-function and death of the patient. Many mechanisms are involved in their occurrence but in the recent past, high portal blood flow through a relatively small liver vascular bed has taken a central role. Therefore, several techniques of inflow modulation have been attempted in cases of portal hyperperfusion first in liver transplantation, such as portocaval shunt, mesocaval shunt, splenorenal shunt, splenectomy or ligation of the splenic artery. However, high portal flow is not the only factor responsible, and before major liver resections, preoperative assessment of the residual liver function is necessary. Techniques such as portal vein embolization or portal vein ligation can be adopted to increase the future liver volume, preventing post-hepatectomy liver failure. More recently, a new surgical procedure, that combines in situ splitting of the liver and portal vein ligation, has gradually come to light, inducing remarkable hypertrophy of the healthy liver in just a few days. Further studies are needed to confirm this hypothesis and overcome one of the biggest issues in the field of liver surgery.World Journal of Gastroenterology 11/2013; 19(44):7922-7929. DOI:10.3748/wjg.v19.i44.7922 · 2.43 Impact Factor
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ABSTRACT: The present study evaluated whether the short- and long-term outcomes improved during our 23 years of experience treating 144 consecutive patients with hilar cholangiocarcinoma. Patients treated between 1990 and 2000 (period 1; n = 70) were retrospectively compared with those treated between 2001 and 2012 (period 2; n = 74). Mortality and major complications were defined as any death occurring within 90 days of surgery and a grade III-IV complication according to the Clavien classification, respectively. The mortality and major complication rates decreased from 1.2 and 34 % during period 1-0 and 24 % during period 2, respectively. Although the surgical procedure was comparable between the two periods, the median blood loss was significantly reduced from 1,020 mL during period 1-745 mL during period 2 (P = 0.003), and blood loss was the only significant predictor of postoperative morbidity in a multivariable analysis. The R0 resection rate (70 vs. 78 %, P = 0.250) and the 5-year survival rate (33 vs. 35 %, P = 0.529) were similar for the two periods. A multivariable analysis identified positive nodal involvement and R1-2 resection as independent prognostic factors for survival. The perioperative outcomes after surgical treatment for hilar cholangiocarcinoma have steadily improved through the accumulation of experience and meticulous surgical techniques to reduce blood loss. Further improvement of the R0 resection rate could prolong patient survival.World Journal of Surgery 12/2013; 38(5). DOI:10.1007/s00268-013-2394-x · 2.35 Impact Factor