Role of caudate lobectomy in type III A and III B hilar cholangiocarcinoma: a 15-year experience in a tertiary institution.

BACKGROUND: Concomitant liver resection for type III hilar cholangiocarcinoma could improve the R0 resection rate and long-term outcome. In the present study, we examine the specific role of caudate lobectomy in liver resection for type III(A) and III(B) hilar cholangiocarcinoma and the prognostic factors for survival in this group of patients. METHODS: We reviewed all patients with type III(A) and III(B) hilar cholangiocarcinoma who underwent liver resection in Samsung Medical Center from January 1995 to July 2010. Patients were divided into those with and without caudate lobectomy (CL). The log rank test and Cox regression analysis were employed to investigate for prognostic factors of survival. RESULTS: There were 127 patients in this cohort, 57 without CL (44.9%) and 70 with CL (55.1%). The demographics and symptoms of presentation were comparable. The median preoperative bilirubin level was significantly higher in the group undergoing CL (p = 0.017). Patients with CL had a significantly better overall survival (OS) (CL: 64.0 months vs without CL: 34.6 months) (p = 0.010) and disease-free survival (DFS) (CL: 40.5 months vs without CL: 27.0 months) (p = 0.031). Multivariate analysis showed that presence of symptoms (p = 0.025) and positive lymph node (LN) metastasis (p < 0.001) were negative prognostic factors for OS. Furthermore, multivariate analysis for DFS found that caudate lobectomy (p = 0.016) and positive LN metastasis (p = 0.001) were positive and negative prognostic factors, respectively. CONCLUSIONS: Caudate lobectomy contributed to improvement of DFS and OS in type III hilar cholangiocarcinoma. Other prognostic factors include positive LN metastasis and presence of symptoms.

Surgical outcomes of 230 resected hilar cholangiocarcinoma in a single centre.

BACKGROUND: Low resectability rate and poor survival outcomes after surgical resection for hilar cholangiocarcinoma are common in most institutions. We retrospectively reviewed the surgical outcomes of hilar cholangiocarcinoma in a tertiary institution focusing on the surgical procedures, radicalities, survival rates and independent prognostic factors. METHODS: Two hundred thirty patients who underwent surgical resection for hilar cholangiocarcinoma between 1995 and 2010 were retrospectively analysed based on the clinical variables, Bismuth-Corlette types, radicality of operation and survival rates. RESULTS: The median overall and disease-free survival time in the whole cohort were 39.1 and 19.2 months, respectively. Patients with type I or II tumour were more likely to undergo segmental bile duct resection than combined liver resection with lower R0 rates (68.2% and 76.1%, respectively). Liver resection (P < 0.001) and combined caudate lobectomy (P = 0.003) were associated with significantly higher R0 rates. Multivariate analysis showed that lymph node metastasis (P = 0.001), preoperative level of bilirubin above 3.0 mg/dL (P = 0.003) and positive resection margin (P = 0.033) were independent prognostic factors on overall survival. CONCLUSION: Liver resection and combined caudate lobectomy increased curative resection rates in hilar cholangiocarcinoma regardless of Bismuth-Corlette types. Preoperative biliary drainage should be performed in jaundiced patients to improve perioperative outcome and survival.

Survival benefits of surgical resection in recurrent cholangiocarcinoma.

PURPOSE: Attempt to identify the beneficial effects associated with surgical procedures on survival outcome of patients with recurrent cholangiocarcinoma. METHODS: 921 patients diagnosed with cholangiocarcinoma underwent surgical resection with curative intent in a single institute during the last 15 years. Patients with recurrent disease were divided into two groups according to whether surgical procedures were performed for the treatment of recurrence. Clinicopathologic variables, ranges of survival based on sites of recurrence, and types of treatment were analyzed retrospectively. RESULTS: The median follow-up period was 21.8 months and 316 (34.3%) patients had recurrence. 27 (group A) patients with recurrent disease were treated surgically and 289 patients (group B) were not treated. Liver resection, metastasectomy, pancreaticoduodenectomy, partial pancreatectomy, and regional lymph node dissection were performed on the patients in group A. The overall survival rate was statistically higher in group A (P = 0.001). Among the surgical procedures, resection of locoregional recurrences (except liver) in abdominal cavity (4.0 to 101.8 months vs. 0.6 to 71.6 months) and metastasectomy of abdominal or chest wall (3.5 to 18.9 months vs. 1.9 to 2.2 months) showed remarkable differences with respect to the range of survival. CONCLUSION: Better survival outcomes can be expected by performing surgical resection of locoregional recurrences (except liver) in abdominal cavity and abdominal or chest wall metastatic lesions in recurrent cholangiocarcinoma.

Potential risk factors for nonalcoholic steatohepatitis related to pancreatic secretions following pancreaticoduodenectomy.

AIM: To identify risk factors for nonalcoholic steatohepatitis following pancreaticoduodenectomy, with a focus on factors related to pancreatic secretions. METHODS: The medical records of 228 patients who had a pancreaticoduodenectomy over a 16-mo period were reviewed retrospectively. The 193 patients who did not have fatty liver disease preoperatively were included in the final analysis. Hepatic steatosis was diagnosed using the differences between splenic and hepatic attenuation and liver-to-spleen attenuation as measured by non-enhanced computed tomography. RESULTS: Fifteen patients (7.8%) who showed postoperative hepatic fatty changes were assigned to Group A, and the remaining patients were assigned to Group B. Patient demographics, preoperative laboratory findings (including levels of C-peptide, glucagon, insulin and glucose tolerance test results), operation types, and final pathological findings did not differ significantly between the two groups; however, the frequency of pancreatic fistula (P = 0.020) and the method of pancreatic duct stenting (P = 0.005) showed significant differences between the groups. A multivariate analysis identified pancreatic fistula (HR = 3.332, P = 0.037) and external pancreatic duct stenting (HR = 4.530, P = 0.017) as independent risk factors for the development of postoperative steatohepatitis. CONCLUSION: Pancreatic fistula and external pancreatic duct stenting were identified as independent risk factors for the development of steatohepatitis following pancreaticoduodenectomy.

Adenocarcinoma of the ampulla of Vater: predictors of survival and recurrence after curative radical resection.

BACKGROUNDS/AIMS: Because of low incidence rates, there have been few reports on the patterns of and risk factors for recurrence after curative resection of the ampulla of Vater (AoV) cancer. The aim of this study was to characterize patterns of recurrence and to evaluate risk factors affecting survival rates and recurrence after curative resection. METHODS: Medical records of 181 patients who had undergone pancreaticoduodenectomy with curative intent for AoV adenocarcinoma between December 1994 and March 2010 at Samsung Medical Center were retrospectively reviewed. Factors influencing on overall survival rate, recurrence rates, and recurrence patterns were analyzed. RESULTS: Lymph node metastases and high preoperative serum carcinoembryonic antigen (CEA) level >5 ng/ml were identified as independent factors affecting overall survival (p=0.006, p<0.001, respectively). Among the 181 patients, 69 developed local or distant recurrence within 3 years after curative resection. Lymph node metastasis, preoperative serum CEA level >5 ng/ml, and total bilirubin level >1.5 mg/dl were identified as independent prognostic factors of recurrence after curative resection (p=0.008, p<0.001, p=0.003, respectively). CONCLUSIONS: AoV adenocarcinoma has a better prognosis than other periampullary carcinomas, but still has a high recurrence rate, especially during the first three years after curative radical resection. Therefore, careful follow-up is needed during the first 3 years, especially for the higher risk group. Further study of adjuvant therapy to decrease recurrence after curative resection is now warranted.

Clinical validation of the ISGPF classification and the risk factors of pancreatic fistula formation following duct-to-mucosa pancreaticojejunostomy by one surgeon at a single center.

BACKGROUND: Postoperative pancreatic fistula remains a troublesome complication after pancreatoduodenectomy (PD), and many authors have suggested factors that affect pancreatic leakage after PD. The International Study Group on Pancreatic Fistula (ISGPF) published a classification, but the new criteria adopted have not been substantially validated. The aims of this study were to validate the ISGPF classification and to analyze the risk factors of pancreatic leakage after duct-to-mucosa pancreatojejunostomy by a single surgeon. METHODS: All patient data were entered prospectively into a database. The risk factors for pancreatic fistula were analyzed retrospectively for 247 consecutive patients who underwent conventional pancreatoduodenectomy or pylorus-preserving pancreatoduodenectomy between June 2005 and March 2009 at the Samsung Medical Center by a single surgeon. Duct-to-mucosa pancreatojejunostomy was performed on all patients. The ISGPF criteria were used to define postoperative pancreatic fistula. RESULTS: Conventional pancreatoduodenectomy was performed in 84 patients and pylorus-preserving pancreatoduodenectomy in 163. Postoperative complications occurred in 144 (58.3%) patients, but there was no postoperative in-hospital mortality. Pancreatic fistula occurred in 105 (42.5%) [grade A, 82 (33.2%); grade B, 9 (3.6%); grade C, 14 (5.7%)]. However, no difference was evident between the no fistula group and the grade A fistula group in terms of clinical findings, including postoperative hospital stays (11 versus 12 days, respectively, p = 0.332). Mean durations of hospital stay in the grade B and C fistula groups were significantly longer than in the no fistula group (21 and 28.5 days, respectively; p < 0.001). Multivariate analysis revealed that a soft pancreas and a long operation time (>300 min) were individually associated with pancreatic fistula formation of grades B and C. CONCLUSIONS: Although the new ISGPF classification appears to be sound in terms of postoperative pancreatic leakage, grade A fistulas lack clinical implications; thus, we are of the opinion that only grade B and C fistulas should be considered in practice. A soft pancreatic texture and an operation time exceeding 300 min were found to be risk factors of grade B and C pancreatic fistulas.