Combined Portal Vein Resection for Hilar Cholangiocarcinoma: A Meta-analysis of Comparative Studies
Department of General Surgery, Xinhua Hospital, Shanghai JiaoTong University School of Medicine, 1665 Kongjiang Rd, Shanghai, 200092, China.Journal of Gastrointestinal Surgery (Impact Factor: 2.8). 04/2013; 17(6). DOI: 10.1007/s11605-013-2202-9
Hilar cholangiocarcinoma (HCCA) frequently invades into the adjacent portal vein, and portal vein resection (PVR) is the only way to manage this condition and achieve negative resection margins. However, the safety and effectiveness of PVR is controversial. Studies analyzing the effect of PVR on the surgical and pathological outcomes in the management of HCCA with gross portal vein involvement were considered eligible for this meta-analysis. The outcome variables analyzed included postoperative morbidity, mortality, survival rate, proportion of R0 resection, lymph node metastasis, microscopic vascular invasion, and perineural invasion. From 11 studies, 371 patients who received PVR and 1,029 who did not were identified and analyzed. Data from patients who received combined PVR correlated with higher postoperative death rates (OR = 2.31; 95 % CI, 1.21-4.43; P = 0.01) and more advanced tumor stage. No significant difference was detected in terms of morbidity, proportion of R0 resection, or 5-year survival rate. Subgroup analysis demonstrated that in centers with more experience or studies published after 2007, combined PVR did not cause significantly higher postoperative death. No strong evidence could suggest that combined PVR leads to more morbidity or mortality for patients with HCCA when the portal vein is grossly involved. In addition, combined PVR is oncologically valuable because R0 resection and 5-year survival did not differ significantly between two cohorts, despite the fact that the PVR cohort consisted of patients with more advanced HCCA.
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ABSTRACT: Hilar cholangiocarcinoma (HC) is a rare disease with a poor prognosis which typically presents in the 6(th) decade of life. Of the 3,000 cases seen annually in the United States, less than one half of these tumors are resectable. A variety of risk factors have been associated with HC, most notably primary sclerosing cholangitis (PSC), biliary stone disease and parasitic liver disease. Patients typically present with abdominal pain, pruritis, weight loss, and jaundice. Computed topography (CT), magnetic resonance imaging (MRI), and ultrasound (US) are used to characterize biliary lesions. Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC) assess local ductal extent of the tumor while allowing for therapeutic biliary drainage. MRCP has demonstrated similar efficacies to PTC and ERCP in identifying anatomic extension of tumors with less complications. Treatment consists of surgery, radiation, chemotherapy and photodynamic therapy. Biliary drainage of the future liver remnant should be performed to decrease bilirubin levels thereby facilitating future liver hypertrophy. Standard therapy consists of surgical margin-negative (R0) resection with extrahepatic bile duct resection, hepatectomy and en bloc lymphadenectomy. Local resection should not be undertaken. Lymph node invasion, tumor grade and negative margins are important prognostic indicators. In instances where curative resection is not possible, liver transplantation has demonstrated acceptable outcomes in highly selected patients. Despite the limited data, chemotherapy is indicated for patients with unresectable tumors and adequate functional status. Five-year survival after surgical resection of HC ranges from 10% to 40% however, recurrence can be as high as 50-70% even after R0 resection. Due to the complexity of this disease, a multi-disciplinary approach with multimodal treatment is recommended for this complex disease.
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ABSTRACT: Background: The surgical approach for hilar cholangiocarcinoma (HC) has largely evolved, and increased resectability rates are reported. Large series of patients with resections for HC were published in the last years, and potential predictors for survival were explored. However, the usefulness of these predictors in clinical decision making is controversial. Purpose: The aim of the present review is to explore the main prognostic factors after curative-intent surgery for HC, as emerged from the current literature. Furthermore, the impact of these predictors on clinical decision making is assessed. Conclusion: An aggressive surgical approach has improved the survival rates in patients with HC and implies bile duct resection associated with liver resection and loco-regional lymph node dissection. The AJCC staging system remains the main tool to assess the prognosis after resection of HC. Margin-negative resections and absence of lymph node metastases are the main prognostic factor after curative-intent surgery for HC. Response to chemotherapy is also a prognostic factor. Markers of systemic inflammatory response might predict prognosis of patients with HC, but their usefulness in clinical decision making remains unclear.
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ABSTRACT: Background: Resection of perihilar cholangiocarcinoma involves major hepatectomy including caudate lobectomy. It is technically challenging because of the complex, intimate and variable relationship between biliary and vascular structures in the liver hilum. Resectability rates vary from 30 to 80 % and about one third of patients have microscopically involved margins. However, adequately performed resections provide 5-year survival of 30-40 % and are worth pursuing. Purpose: Better understanding of anatomy, better imaging, improved surgical techniques and progress in perioperative care of these patients have pushed the limits of resection of these tumours. Many of the traditional indicators of inoperability such as bilateral involvement of second-order hepatic ducts, contralateral biliary and vascular involvement, and need for arterial resection have been overcome or are being challenged. This review discusses techniques that may increase margin-free resectability of Bismuth-Corlette type III and IV perihilar cholangiocarcinoma. Conclusion: Advanced perihilar cholangiocarcinoma requires extended liver resection and often vascular resection, despite which the margin may be compromised in about one third of patients. Right sided tumours are likely to need right trisectionectomy and portal vein resection, best served by an en bloc hilar resection or Rex-recess approach. Left-sided tumours often involve contralateral blood vessels and require left trisegmentectomy with possible right portal vein or right hepatic artery reconstruction. These tumours are best tackled by hepatobiliary surgeons with experience in microvascular techniques. Salvage procedures when arterial reconstruction is not feasible are still under evaluation.
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