Introduction
A grey zone known as the borderline resectable (BR) category, which lies between resectable and unresectable, has been proposed for perihilar cholangiocarcinoma; however, there is no international consensus on this classification. BR can be considered from various perspectives, including local tumor factors, surgical risk, long-term prognosis, liver reserve capacity, and systemic condition.
Aims & Methods
The study's aim is to define the borderline resectable (BR) of perihilar cholangiocarcinoma based on surgical procedure and preoperative liver function. We examined 1) the comparison of surgical outcomes between extended surgery and standard surgery and 2) the risk of postoperative mortality from liver failure in patients who underwent portal vein embolization.
Study 1) Surgical cases from January 2011 to December 2023 were divided into two groups: the Extended surgery group: left or right trisectionectomy(L3/R3), concomitant hepatic artery resection (AR), hepatopancreaticoduodenectomy (HPD), and the other standard surgery groups. Study 2) The risk of postoperative liver failure in patients who underwent resection after portal vein embolization (PVE) between January 2001 and December 2022 (including HPD) was evaluated
Results
Study 1) A total of 181 patients (59 in the extended surgery group and 122 in the standard surgery group) were included in the study. There were significant differences in operation time (median 798/700 minutes, p<0.01) and blood loss (2000 ml/1295 ml, p<0.01) in the extended surgery group compared to the standard surgery group, but no significant differences in postoperative complication rate (Clavien Dindo 3a or higher: 79%/67%) or in-hospital mortality rate (5%/5%). The 5-year overall survival rate was 34% in the extended surgery group and 50% in the standard surgery group, which was not significantly different by the log-rank test. Study 2: The incidence of liver failure (%) and mortality (%) by surgical technique were R (37/5.7), L3 (30/5), and R3 (54/7.7). ICGK x proportion of remnant liver volume（ICGKF）<0.05 before PVE, operation time >660 minutes, and blood loss >1900 ml were identified as risk factors in univariate and multivariate analyses, and the mortality rate for patients with these three factors was high at 25%.
Conclusion
Patients who required extended surgery with poor pre-PVE liver function (ICGKF<0.05) should be considered BR in perihilar cholangiocarcinoma.
References
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