Aggressive surgical resection for cholangiocarcinoma

W. K. Washburn, W. D. Lewis and R. L. Jenkins
Division of Hepatobiliary Surgery and Liver Transplantation, New England Deaconess Hospital, Boston, Mass.

OBJECTIVES: To review the spectrum of cholangiocarcinoma in patients treated by a single team of hepatobiliary surgeons over an 8-year period, to evaluate the predictors of survival, and to assess the results of an aggressive approach to surgical resection. DESIGN: Retrospective review of all clinical records of patients referred for treatment of cholangiocarcinoma, with univariate analysis of clinical and pathologic factors in relation to patient survival. SETTING: New England Deaconess Hospital, Boston, Mass. PATIENTS: Eighty-eight consecutive patients referred with the established diagnosis of cholangiocarcinoma, from December 31, 1985, to April 15, 1994. INTERVENTIONS: Seventy-five of 88 patients were treated surgically, with 59 undergoing major resection for cure. Of the 29 patients treated palliatively, 16 had operations and 13 had wire mesh stents placed nonoperatively. MAIN OUTCOME MEASURES: Morbidity, mortality, and patient survival. RESULTS: Survival correlates directly with the pathologic stage (TNM). Tumor location had no impact on survival. Patients undergoing resection survived significantly longer (median, 23.2 months) than palliated patients (median, 7.7 months; P = .0015). Nonoperative palliation resulted in better survival than surgical palliation (P = .045). Major hepatic resection was used alone in eight patients with predominating intrahepatic lesions, while 18 patients with hilar lesions underwent en bloc skeletonization in conjunction with major hepatic resection. Resection with microscopically free margins significantly improved survival. Only patients undergoing major resection enjoyed survival greater than 2 years. CONCLUSIONS: Patient survival can be significantly improved by aggressive surgical resection. Hepatic resection should be used aggressively to achieve disease-free margins to optimize survival. Hepatic resection can be performed with low morbidity and mortality. Liver transplantation should be avoided as a treatment for cholangiocarcinoma. The best palliation for unresectable disease remains debatable. We advocate nonoperative treatment with endobiliary expandable wire mesh stents for patients with unresectable disease.

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