Transhepatic Direct Approach to the “Limit of the Division of the Hepatic Ducts” Leads to a High R0 Resection Rate in Perihilar Cholangiocarcinoma

Abstract

Background

Previous studies have shown that curative resection (R0 resection) was among the most crucial factors for the long-term survival of patients with PHCC. To achieve R0 resection, we performed the transhepatic direct approach and resection on the limits of division of the hepatic ducts. Although a recent report showed that the resection margin (RM) status impacted PHCC patients’ survival, it is still unclear whether RM is an important clinical factor.

Objective

To describe a technique of transhepatic direct approach and resection on the limit of division of hepatic ducts, investigate its short-term surgical outcome, and validate whether the radial margin (RM) would have a clinical impact on long-term survival of perihilar cholangiocarcinoma (PHCC) patients.

Methods

Consecutive PHCC patients (n = 211) who had undergone major hepatectomy with extrahepatic bile duct resection, without pancreaticoduodenectomy, in our department were retrospectively evaluated.

Results

R0 resection rate was 92% and 86% for invasive cancer-free and both invasive cancer-free and high-grade dysplasia-free resection, respectively. Overall 5-year survival rate was 46.9%. Univariate analysis showed that preoperative serum carcinoembryonic antigen level (> 7.0 mg/dl), pathological lymph node metastasis, and portal vein invasion were independent risk factors, but R status on both resection margin and bile duct margin was not an independent risk factor for survival.

Conclusion

The transhepatic direct approach to the limits of division of the bile ducts leads to the highest R0 resection rate in the horizontal margin of PHCC. Further examination will be needed to determine the adjuvant therapy for PHCC to improve patient survival.

Introduction

Previous reports have shown that curative resection (R0 resection) was among the most crucial long-term survival factors in patients with perihilar cholangiocarcinoma (PHCC).1^,2 Several studies conducted at high-volume centers showed R0 resection rate for PHCC of 63–83.2%.2., 3., 4., 5., 6., 7., 8., 9., 10., 11., 12. To achieve R0 resection, Kondo et al.1 (our department) previously advocated guidelines for PHCC surgery and reported that surgery under these guidelines could lead to a high R0 resection rate with no mortality. This guideline included the concept of “transhepatic direct approach to the limits dividing the hepatic ducts from the vasculature and ductal division”: an intrahepatic duct goes behind and is covered by a portal branch, which should be preserved; the point where the bile duct cannot be further separated from the vasculature is “intrahepatic bile duct resection on limit of dividing of the hepatic ducts,” which is an anatomically regulated point, and we believed it is unique in each type of hepatectomy,13 which could lead R0 resection on horizontal bile ductal margin (BM) in PHCC.

Today, “a transhepatic direct approach to the bile duct” would begin to be the standard procedure for PHCC surgery.14., 15., 16. However, only a few surgeons have performed the transhepatic direct approach to “the limits of division of the bile ducts”; thus, only a few reports have described this surgical technique.13^,17., 18., 19. Moreover, there has been no study investigating the short- and long-term results of this technique. Although a recent report showed that the RM status impacted PHCC patients’ survival, it is still unclear whether radial margin (RM) is an important clinical factor.

Thus, we aimed to describe our technique of transhepatic direct approach to the limits of division of the bile duct and investigate the short-term surgical outcome of this technique, including R status on BM/RM, mortality, and morbidity.