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Analysis of 46 Patients

David J. Rea, MD; Manuel Munoz-Juarez, MD; Michael B. Farnell, MD; John H. Donohue, MD; Florencia G. Que, MD; Brian Crownhart, BS; Dirk Larson, MS; David M. Nagorney, MD

Arch Surg. 2004;139:514-525.

Hypothesis  Major hepatectomy, bile duct resection, and regional lymphadenectomy for hilar cholangiocarcinoma are associated with actual long-term (>5 years) survival.

Design  Retrospective outcome study.

Setting  Single tertiary referral institution.

Patients  Between 1979 and 1997, 46 consecutive patients had resection of hilar cholangiocarcinoma by major hepatectomy, bile duct resection, and regional lymphadenectomy.

Main Outcome Measures  Overall survival and tumor recurrence were correlated to clinicopathological factors, operative morbidity, and mortality.

Results  Twenty-five patients underwent left hepatectomy, 17 underwent right hepatectomy, and 4 had extended right hepatectomy. Eighteen patients underwent resection of segment 1. Negative (R0) resection margins were achieved in 37 patients (80%). The operative mortality rate was 9%, and the surgical morbidity rate was 52%. Actual 1-year, 3-year, and 5-year survival rates were 80%, 39%, and 26%, respectively. Factors adversely associated with patient survival rates included: male sex, lymph node metastases, tumor grade 3 or 4, elevated direct serum bilirubin level at diagnosis, elevated preoperative activated partial thromboplastin time, and more than 4 U of red blood cells transfused perioperatively. Tumor size and R0 resection approached significance for survival. Factors associated with tumor recurrence included: male sex, tumor grade 3 or 4, a low hemoglobin level both at diagnosis and preoperatively, and a low preoperative prothrombin time and low alkaline phosphatase level at diagnosis and preoperatively. Median time to recurrence was 3.6 years. Tumor recurrence was predominantly local and regional.

Conclusions  The actual 5-year survival rate of 26% justifies major partial hepatectomy, bile duct resection, and regional lymphadenectomy for hilar cholangiocarcinoma. The high frequency of local and regional recurrence warrants investigation of adjuvant therapy.

From the Department of Surgery, Divisions of Gastroenterologic and General Surgery (Drs Rea, Munoz-Juarez, Farnell, Donohue, Que, and Nagorney) and Biostatistics (Messrs Crownhart and Larson), Mayo Clinic College of Medicine, Rochester, Minn.

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