59例肝门部胆管癌切除术后并发症和生存率分析

doi:10.24920/003565

摘要/Abstract

摘要： 目的肝门部胆管癌（HC）非手术治疗基本上是不可治愈的。本研究旨在明确HC手术切除的安全性和术后生存率,并且研究影响切除术后生存率的预后因素。方法以2009年2月至2017年2月完成的59例手术切除的HC病人为研究对象,出院后每隔3-6个月对病人进行随访,明确术后并发症和总体生存率,并通过单因素和Cox回归分析,研究患者临床、病理和手术因素中与总体生存率相关的预后因素。结果 59例外科治疗的HC病人中,33例（55.9％）Bismuth & Corlette（B & C）Ⅲ型（n=19）和Ⅳ型（n=25）采用肝门部切除联合大部肝切除（MLR）治疗,其余11例Ⅲ-Ⅳ型HC病人与Ⅰ型（n=8）和Ⅱ型（n=7）HC病人均采用肝门切除术。本组HC病人的死亡率为5.1％,手术并发症发生率为35.6％。肝门切除+MLR组的死亡率（6.1％）与肝门部切除的死亡率（3.8％）之间无统计学差异（Χ ²=0.703,P=0.145）。本组病人中位随访期为18个月（1-94个月）,1、3、5年生存率分别为59.3％、36.5％和17.7％,总生存期为18个月。在Ⅲ型和Ⅳ型HC病人中,行肝门切除+MLR的中位生存期为23个月,而行肝门切除术的中位生存期为8个月;前者的1、3、5年累积生存率分别为63.9％、23.3％和15.5％,而后者1、3、5年累积生存率分别为11.1％、0和0,在两种术式间存在显著差异（HR,9.902;95% CI,2.636-19.571,P=0.001）。与术后生存率相关的四个独立预后因素分别为：术前血清Ca19-9水平（HR,7.039;95% CI,2.803-17.678,P<0.001）,组织病理学分级（HR,4.964;95% CI,1.046-23.552,P<0.05）,手术切缘（P<0.05）和AJCC分期（P<0.05）。结论 R0切除是HC外科治疗的有效方法。MLR结合尾状叶切除可以增加Ⅲ型和Ⅳ型HC病人R0切除的机会,并提高术后生存率。对合适的HC病人行胆道引流的术前准备,可以确保绝大多数病人安全的接受MLR。应研究新的辅助疗法以改善具有不良预后因素的HC病人的生存率。

关键词: 发病率, 死亡, 预后, 肝门部胆管癌, 肝切除术

Abstract:

Objective Hilar cholangiocarcinoma (HC) is invariably fatal without surgical resection. The primary aim of the current study was to determine the safety of variable surgical resections for patient with HC and their survival after surgical resection. In addition, prognostic factor for the overall survival was also evaluated. Methods The study included 59 consecutive patients who were newly diagnosed with HC and underwent surgical resections with curative intend between February 2009 and February 2017. Patients were followed up at 3-6 months intervals after hospital discharge. Postoperative complications and overall survival were determined. Associations of clinicopathologic and surgeon-related factors with overall survival were evaluated through univariate analysis and Cox regression analysis. Results Of patients with Bismuth and Corlette (B & C) type Ⅲ (n=19) and Ⅳ (n=25) HC lesions, 33 (55.9%) were treated with hilar resection combined with major liver resection (MLR), while the other 11 patients with type Ⅲ and Ⅳ, and those with type Ⅰ (n=8) and Ⅱ (n=7) HC lesions were treated with hilar resection. The overall surgical mortality was 5.1% and surgical morbidity was 35.6%. There was no statistical difference in the mortality between MLR group and hilar resection group (6.1% vs. 3.8%; X²=0.703, P=0.145). The median follow-up period was 18 months (range, 1-94 months). The 1-, 3-, 5-year survival rate was 59.3%, 36.5%, and 17.7%, respectively. The overall survival after resections was 18 months. In HC patients with B & C type Ⅲ and Ⅳ lesions, the median survival was 23 months for hilar resection with MLR and 8 months for hilar resection alone; the 1-, 3-, 5-year cumulative survival rate was 63.9%, 23.3%, and 15.5%, respectively for hilar resection with MLR, and 11.1%, 0, and 0, respectively for hilar resection alone, with significant differene observed (HR, 9.902; 95% CI, 2.636-19.571, P=0.001). Four factors were independently associated with overall survival: preoperative serum Ca19-9 (HR, 7.039; 95% CI, 2.803-17.678, P<0.001), histopathologic grade (HR, 4.964; 95% CI, 1.046-23.552, P=0.044), surgical margins (P=0.031), and AJCC staging (P=0.015). Conclusions R0 resection is efficacious in surgical treatment of HC. MLR in combination with caudate lobe resection may increase the chance of R0 resection and improve survival of HC patients with B & C type Ⅲ and Ⅳ lesions. Preoperatively prepared for biliary drainage may ensure the safety of MLR in most HC patients. Novel adjuvant therapies are needed to improve the survival of HC patients with poor prognostic factors.

Key words: morbidity, mortality, prognosis, hilar cholangiocarcinoma, hepatectomy

Zhu Weihua,Xie Wenyong,Zhang Zhedong,Li Shu,Zhang Dafang,Liu Yijun,Zhu Jiye,Leng Xisheng. Postoperative Complications and Survival Analysis of Surgical Resection for Hilar Cholangiocarcinoma: A Retrospective Study of Fifty-Nine Consecutive Patients[J].Chinese Medical Sciences Journal, 2020, 35(2): 157-169.

图/表 8

Variables	1-year survival rate (n=50)	P / χ²_log-rank	3-year survival rate (n=44)	P / χ²_log-rank	5-year survival rate (n=31)	P / χ²_log-rank
Gender		0.547/0.363		0.071/3.267^#		0.097/2.747^#
Male	61.3% (31)		31.3% (29)		23.8%/(21)
Female	52.6% (19)		6.7% (15)		0 (10)
Age (years)		0.291/1.116		0.051/3.799^#		0.124/2.360^#
≥65	68.8% (16)		6.3% (16)		0 (9)
<65	52.9% (34)		32.1% (28)		22.7% (22)
Hypertension		0.658/0.196		0.415/0.664^#		0.436/0.607^#
Yes	62.5% (16)		30.8% (13)		25.0% (8)
No	55.9% (34)		19.4% (31)		13.0% (23)
Diabetes Mellitus		0.925/0.009^#		0.910/0.013^#		0.528/0.398^#
Yes	60% (5)		25% (4)		0 (2)
No	57.8% (45)		22.5% (40)		17.2% (29)
Chronic hepatitis		0.093/2.819^#		0.839/0.041^#		0.661/0.192^#
Yes	0 (2)		0 (2)		0 (1)
No	60.4% (48)		23.8% (42)		16.7% (30)
T-Bil		0.650/0.206^#		0.510/0.435^#		0.432/0.618^#
≥2 mg/dL	66.7% (44)		21.1% (38)		17.9% (28)
<2 mg/dL	56.8% (6)		33.3% (6)		0 (3)
Preoperative Ca19-9		0.001/18.252		0.040/4.216^#		0.124/2.360^#
≥1000 U/mL	7.7% (13)		0 (11)		0 (9)
<1000 U/mL	75.7% (37)		30.3% (33)		22.7% (22)
CEA		0.015/5.884^#		0.336/0.925^#		0.432/0.618^#
≥4.7 ng/mL	0 (4)		0 (3)		0 (3)
<4.7 ng/mL	63.0% (46)		24.4% (41)		17.9% (28)
B&C type（1 st）*		0.493/0.470^#		0.277/1.183^#		0.609/0.261^#
Ⅰ	57.1% (7)		33.3% (6)		20.0% (5)
Ⅱ	85.7% (7)		33.3% (6)		33.3% (3)
Ⅲ	50% (14)		23.1% (13)		11.1% (9)
Ⅳ	54.5% (22)		15.8% (19)		14.3% (14)
B&C type（2nd）*		0.230/1.439		0.309/1.033^#		0.436/0.607^#
Ⅰ and Ⅱ	71.45 (14)		33.3% (12)		25.0% (8)
Ⅲ and Ⅳ	52.8% (36)		18.8% (32)		13.1% (23)
B&C type（3rd）*		0.793/0.069^#		0.610/0.261^#		0.829/0.047^#
Ⅲ	50.0% (14)		23.1% (13)		11.1% (9)
Ⅳ	54.5% (22)		15.8% (19)		14.3% (14)
B&C type（4th）*		0.298/1.083^#		0.626/0.238^#		0.264/1.250^#
Ⅲa	33.3% (6)		16.7% (6)		0 (5)
Ⅲb	62.5% (8)		28.6% (7)		25.0% (4)
Drainage		0.314/1.012		0.280/1.167^#		0.969/0.002^#
Yes	46.2% (13)		10.0% (10)		16.7% (6)
No	62.2% (37)		26.5% (34)		16.0% (25)
Chemotherapy		0.053/3.871^#		0.400/0.708^#		0.468/0.527^#
Yes	90.0% (10)		30.0% (10)		25.0% (8)
No	50.0% (40)		17.6% (34)		13.6% (22)

参考文献 57.

1.	Altemeier WA, Gall EA, Zinninger MM , et al. Sclerosing carcinoma of the major intrahepatic bile ducts. AMA Arch Surg 1957; 75(3):450-60. doi: 10.1001/archsurg.1957.01280150140015. doi: 10.1001/archsurg.1957.01280150140015 pmid: 13457619
2.	Klatskin G . Adenocarcinoma of the hepatic duct at its bifurcation within the porta hepatis: an unusual tumor with distinctive clinical and pathological features. Am J Med 1965; 38(2):241-56. doi: 10.1016/0002-9343(65)90178-6. doi: 10.1016/0002-9343(65)90178-6
3.	Bismuth H, Nakache R, Diamond T . Management strategies in resection for hilar cholangiocarcinoma. Ann Surg 1992; 215(1):31-8. doi: 10.1097/00000658-199201000-00005. doi: 10.1097/00000658-199201000-00005 pmid: 1309988
4.	Hemming AW, Reed AI, Fujita S , et al. Surgical management of hilar cholangiocarcinoma. Ann Surg 2005; 241(5):693-9. doi: 10.1097/01.sla.0000160701.38945.82. doi: 10.1097/01.sla.0000160701.38945.82 pmid: 15849505
5.	Sano T, Shimada K, Sakamoto Y , et al. One hundred two consecutive hepatobiliary resections for perihilar cholangiocarcinoma with zero mortality. Ann Surg 2006; 244(2):240-7. doi: 10.1097/01.sla.0000217605.66519.38. doi: 10.1097/01.sla.0000217605.66519.38 pmid: 16858186
6.	Miyazaki M, Ito H, Nakagawa K , et al. Segments Ⅰ and Ⅳ resection as a new approach for hepatic hilar cholangiocarcinoma. Am J Surg 1998; 175(3):229-31. doi: 10.1016/s0002-9610(97)00295-x. doi: 10.1016/s0002-9610(97)00295-x pmid: 9560126
7.	Gerhards MF, van Gulik TM, de Wit LT , et al. Evaluation of morbidity and mortality after resection for hilar cholangiocarcinoma: a single center experience. Surgery 2000; 127(4):395-404. doi: 10.1067/msy.2000.104250. doi: 10.1067/msy.2000.104250 pmid: 10776430
8.	Tirelli G, Gatto A, Boscolo NF , et al. Prognosis of oral cancer: a comparison of the staging systems given in the 7th and 8th editions of the American Joint Committee on Cancer Staging Manual. Bri J Oral Maxillofac Surg 2018; 56(1):8-13. doi: 10.1016/j.bjoms.2017.11.009.
9.	Gaspersz M, Buettner S, Van Vugt J , et al. Evaluation of the New American Joint Committee on cancer staging manual 8th edition for perihilar cholangiocarcinoma. HPB 2018; 20(5):S182-3. doi: 10.1016/j.hpb.2018.06.023.
10.	Bas GK, Jimme KW, Peter JA , et al. American Joint Committee on Cancer staging for resected perihilar cholangiocarcinoma: a comparison of the 6th and 7th editions. HPB (Oxford) 2014; 16(12):1074-82. doi: 10.1111/hpb.12320. doi: 10.1111/hpb.12320
11.	Wente MN, Bassi C, Dervenis C . Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2007; 142(5):761-8. doi: 10.1016/j.surg.2007.05.005. doi: 10.1016/j.surg.2007.05.005 pmid: 17981197
12.	Vincent JL . Sepsis definitions. Lancet Infect Dis 2002; 2(3):135. doi: 10.1016/s1473-3099(02)00232-3. doi: 10.1016/s1473-3099(02)00232-3 pmid: 11944181
13.	Nikpour AM, Knebel RJ, Cheng D , et al. Diagnosis and management of postoperative biliary leaks. Semin Intervent Radiol 2016; 33(4):307-12. doi: 10.1055/s-0036-1592324. doi: 10.1055/s-0036-1592324 pmid: 27904250
14.	Koch M, Garden OJ, Padbury R , et al. Bile leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the International Study Group of Liver Surgery. Surgery 2011; 149(5):680-8. doi: 10.1016/j.surg.2010.12.002. doi: 10.1016/j.surg.2010.12.002
15.	Blanc T, Cortes A, Goere D , et al. Hemorrhage after pancreaticoduodenectomy: when is surgery still indicated? Am J Surg 2007; 194(1):3-9. doi: 10.1016/j.amjsurg.2006.08.088. doi: 10.1016/j.amjsurg.2006.08.088 pmid: 17560900
16.	Wente MN, Veit JA, Bassi C , et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 2007; 142(1):20-5. doi: 10.1016/j.surg.2007.02.001. doi: 10.1016/j.surg.2007.02.001 pmid: 17629996
17.	Rahbari NN, Garden OJ, Padbury R , et al. Post-hepatectomy haemorrhage: a definition and grading by the International Study Group of Liver Surgery (ISGLS). HPB (Oxford) 2011; 13(8):528-35. doi: 10.1111/j.1477-2574.2011.00319.x. doi: 10.1111/j.1477-2574.2011.00319.x
18.	Rahbari NN, Garden OJ, Padbury R , et al. Posthepatectomy liver failure: a definition and grading by the International Study Group of Liver Surgery (ISGLS). Surgery 2011; 149(5):713-24. doi: 10.1016/j.surg.2010.10.001. doi: 10.1016/j.surg.2010.10.001
19.	Kawasaki S, Imamura H, Kobayashi A , et al. Results of surgical resection for patients with hilar bile duct cancer: application of extended hepatectomy after biliary drainage and hemihepatic portal vein embolization. Ann Surg 2003; 238(1):84-92. doi: 10.1097/01.sla.0000074984.83031.02. doi: 10.1097/01.SLA.0000074984.83031.02 pmid: 12832969
20.	Dinant S, Gerhards MF, Rauws EA , et al. Improved outcome of resection of hilar cholangiocarcinoma (Klatskin tumor). Ann Surg Oncol 2006; 13(6):872-80. doi: 10.1245/aso.2006.05.053. doi: 10.1245/ASO.2006.05.053
21.	Seyama Y, Kubota K, Sano K , et al. Long-term outcome of extended hemihepatectomy for hilar bile duct cancer with no mortality and high survival rate. Ann Surg 2003; 238(1):73-83. doi: 10.1097/01.sla.0000074960.55004.72. doi: 10.1097/01.SLA.0000074960.55004.72 pmid: 12832968
22.	Nakeeb A, Pitt HA, Sohn TA , et al. Cholangiocarcinoma. A spectrum of intrahepatic, perihilar, and distal tumors. Ann Surg 1996; 224(4):463-75. doi: 10.1097/00000658-199610000-00005. doi: 10.1097/00000658-199610000-00005 pmid: 8857851
23.	Todoroki T, Kawamoto T, Koike N , et al. Radical resection of hilarbile duct carcinoma and predictors of survival. Br J Surg 2000; 87(3):306-13. doi: 10.1046/j.1365-2168.2000.01343.x. doi: 10.1046/j.1365-2168.2000.01343.x pmid: 10718799
24.	Nimura Y, Kamiya J, Kondo S , et al. Aggressive preoperative management and extended surgery for hilar cholangiocarcinoma: Nagoya experience. J Hepatobiliary Pancreat Surg 2000; 7(2):155-62. doi: 10.1007/s005340050170. doi: 10.1007/s005340050170 pmid: 10982608
25.	Klempnauer J, Ridder GJ, von Wasielewski R, et al. Resectional surgery of hilar cholangiocarcinoma: a multivariate analysis of prognostic factors. J Clin Oncol 1997; 15(3):947-54. doi: 10.1200/jco.1997.15.3.947. doi: 10.1200/JCO.1997.15.3.947 pmid: 9060532
26.	Kondo S, Hirano S, Ambo Y , et al. Forty consecutive resections of hilar cholangiocarcinoma with no postoperative mortality and no positive ductal margins: results of a prospective study. Ann Surg 2004; 240(1):95-101. doi: 10.1097/01.sla.0000129491.43855.6b. doi: 10.1097/01.sla.0000129491.43855.6b pmid: 15213624
27.	Rea DJ, Munoz-Juarez M, Farnell MB , et al. Major hepatic resection for hilar cholangiocarcinoma: analysis of 46 patients. Arch Surg 2004; 139(5):514-23. doi: 10.1001/archsurg.139.5.514. doi: 10.1001/archsurg.139.5.514 pmid: 15136352
28.	Kang MJ, Jang JY, Chang J , et al. Actual long-term survival outcome of 403 consecutive patients with hilar cholangiocarcinoma. World J Surg 2016; 40(10):2451-9. doi: 10.1007/s00268-016-3551-9. doi: 10.1007/s00268-016-3551-9 pmid: 27206402
29.	MC de Jong, Marques H, Clary BM , et al. The impact of portal vein resection on outcomes for hilar cholangiocarcinoma: a multi-institutional analysis of 305 cases. Cancer 2012; 118(19):4737-47. doi: 10.1002/cncr.27492. doi: 10.1002/cncr.27492 pmid: 22415526
30.	Hemming AW, Mekeel K, Khanna A , et al. Portal vein resection in management of hilar cholangiocarcinoma. J Am Coll Surg 2011; 212(4):604-13. doi: 10.1016/j.jamcollsurg.2010.12.028. doi: 10.1016/j.jamcollsurg.2010.12.028 pmid: 21463797
31.	Saxena A, Chua TC, Chu FC , et al. Improved outcomes after aggressive surgical resection of hilar cholangiocarcinoma: a critical analysis of recurrence and survival. Am J Surg 2011; 202(3):310-20. doi: 10.1016/j.amjsurg.2010.08.041. doi: 10.1016/j.amjsurg.2010.08.041
32.	Scurtu RR, Dindelegan G, Bintintan V , et al. Extension of hepatic resection ameliorates survival in patients with type Ⅲ a or Ⅲ b klatskin tumors despite surgical complications. Chirurgia (Bucur) 2017; 112(3):301-7. doi: 10.21614/chirurgia.112.3.301.
33.	Cheng QB, Yi B, Wang JH , et al. Resection with total caudate lobectomy confers survival benefit in hilar cholangiocarcinoma of Bismuth type Ⅲ and Ⅳ. Eur J Surg Oncol 2012; 38(12):1197-203. doi: 10.1016/j.ejso.2012.08.009. doi: 10.1016/j.ejso.2012.08.009 pmid: 22992326
34.	Xiong J, Nunes QM, Huang W , et al. Major hepatectomy in Bismuth types Ⅰ and Ⅱ hilar cholangiocarcinoma. J Surg Res 2015; 194(1):194-201. doi: 10.1016/j.jss.2014.10.029. doi: 10.1016/j.jss.2014.10.029 pmid: 25454973
35.	Miyazaki M, Kimura F, Shimizu H , et al. One hundred seven consecutive surgical resections for hilar cholangiocarcinoma of Bismuth types Ⅱ, Ⅲ, Ⅳ between 2001 and 2008. J Hepatobiliary Pancreat Sci 2010; 17(4):470-5. doi: 10.1007/s00534-009-0207-2. doi: 10.1007/s00534-009-0207-2 pmid: 19936600
36.	Abd El Wahab M, El Nakeeb A, El Hanafy E , et al. Predictors of long term survival after hepatic resection for hilar cholangiocarcinoma: A retrospective study of 5-year survivors. World J Gastrointest Surg 2016; 8(6):436-43. doi: 10.4240/wjgs.v8.i6.436. doi: 10.4240/wjgs.v8.i6.436 pmid: 27358676
37.	Li M, Li K, Qi X , et al. Percutaneous transhepatic biliary stent implantation for obstructive jaundice of perihilar cholangiocarcinoma: a prospective study on predictors of stent patency and survival in 92 patients. J Vasc Interv Radiol 2016; 27(7):1047-55. doi: 10.1016/j.jvir.2016.02.035. doi: 10.1016/j.jvir.2016.02.035 pmid: 27241392
38.	Juntermanns B, Radunz S, Heuer M , et al. Tumor markers as a diagnostic key for hilar cholangiocarcinoma. Eur J Med Res 2010; 15(8):357-61. doi: 10.1186/2047-783x-15-8-357. doi: 10.1186/2047-783x-15-8-357 pmid: 20947473
39.	Hasegawa S, Ikai I, Fujii H , et al. Surgical resection of hilar cholangiocarcinoma: analysis of survival and postoperative complications. World J Surg 2007; 31(6):1256-63. doi: 10.1007/s00268-007-9001-y. doi: 10.1007/s00268-007-9001-y pmid: 17453285
40.	Yubin L, Chihua F, Zhixiang J , et al. Surgical management and prognostic factors of hilar cholangiocarcinoma: experience with 115 cases in China. Ann Surg Oncol 2008; 15(8):2113-9. doi: 10.1245/s10434-008-9932-z. doi: 10.1245/s10434-008-9932-z
41.	Ebata T, Nagino M, Kamiya J , et al. Hepatectomy with portal vein resection for hilar cholangiocarcinoma: audit of 52 consecutive cases. Ann Surg 2003; 238(5):720-7. doi: 10.1097/01.sla.0000094437.68038.a3. doi: 10.1097/01.sla.0000094437.68038.a3 pmid: 14578735
42.	Kitagawa Y, Nagino M, Kamiya J , et al. Lymph node metastasis from hilar cholangiocarcinoma: audit of 110 patients who underwent regional and paraaortic node dissection. Ann Surg 2001; 233(3):385-92. doi: 10.1097/00000658-200103000-00013. doi: 10.1097/00000658-200103000-00013 pmid: 11224627
43.	Rea DJ, Munoz-Juarez M, Farnell MB , et al. Major hepatic resection for hilar cholangiocarcinoma: analysis of 46 patients. Arch Surg 2004; 139(5):514-23. doi: 10.1001/archsurg.139.5.514. doi: 10.1001/archsurg.139.5.514 pmid: 15136352
44.	Ito F, Cho CS, Rikkers LF , et al. Hilar cholangiocarcinoma: current management. Ann Surg 2009; 250(2):210-8. doi: 10.1097/sla.0b013e3181afe0ab. doi: 10.1097/SLA.0b013e3181afe0ab pmid: 19638920
45.	Witzigmann H, Berr F, Ringel U , et al. Surgical and palliative management and outcome in 184 patients with hilar cholangiocarcinoma: palliative photodynamic therapy plus stenting is comparable to R1/R2 resection. Ann Surg 2006; 244(2):230-9. doi: 10.1097/01.sla.0000217639.10331.47. doi: 10.1097/01.sla.0000217639.10331.47 pmid: 16858185
46.	Ito F, Agni R, Rettammel RJ , et al. Resection of hilar cholangiocarcinoma: concomitant liver resection decreases hepatic recurrence. Ann Surg 2008; 248(2):273-9. doi: 10.1097/sla.0b013e31817f2bfd. doi: 10.1097/SLA.0b013e31817f2bfd pmid: 18650638
47.	Su CH, Tsay SH, Wu CC , et al. Factors influencing postoperative morbidity, mortality, and survival after resection for hilar cholangiocarcinoma. Ann Surg 1996; 223(4):384-94. doi: 10.1097/00000658-199604000-00007. doi: 10.1097/00000658-199604000-00007 pmid: 8633917
48.	Kosuge T, Yamamoto J, Shimada K , et al. Improved surgical results for hilar cholangiocarcinoma with procedures including major hepatic resection. Ann Surg 1999; 230(5):663-71. doi: 10.1097/00000658-199911000-00008. doi: 10.1097/00000658-199911000-00008 pmid: 10561090
49.	Nagino M, Kamiya J, Uesaka K , et al. Complications of hepatectomy for hilar cholangiocarcinoma. World J Surg 2001; 25(10):1277-83. doi: 10.1007/s00268-001-0110-8. doi: 10.1007/s00268-001-0110-8
50.	Yu FX, Ji SQ, Su LF , et al. Effectiveness and safety of preoperative percutaneous transhepatic cholangiodrainage with bile re-infusion in patients with hilar cholangiocarcinoma: a retrospective controlled study. Am J Med Sci 2013; 346(5):353-7. doi: 10.1097/maj.0b013e3182755de6.
51.	Kennedy TJ, Yopp A, Qin Y , et al. Role of preoperative biliary drainage of liver remnant prior to extended liver resection for hilar cholangiocarcinoma. HPB (Oxford) 2009; 11(5):445-51. doi: 10.1111/j.1477-2574.2009.00090.x. doi: 10.1111/j.1477-2574.2009.00090.x
52.	Xiong JJ, Nunes MQ, Huang W , et al. Preoperative biliary drainage in patients with hilar cholangiocarcinoma undergoing major hepatectomy. World J Gastroenterol 2013; 19(46):8731-9. doi: 10.3748/wjg.v19.i46.8731. doi: 10.3748/wjg.v19.i46.8731 pmid: 24379593
53.	Farges O, Regimbeau JM, Fuks D , et al. Multicentre European study of preoperative biliary drainage for hilar cholangiocarcinoma. Br J Surg 2013; 100(2):274-83. doi: 10.1002/bjs.8950. doi: 10.1002/bjs.8950 pmid: 23124720
54.	El-Hanafy E . Pre-operative biliary drainage in hilar cholangiocarcinoma, benefits and risks, single center experience. Hepatogastroenterology 2010; 57(99-100):414-9. doi: 10.1136/gut.2009.183046. pmid: 20698200
55.	Gerhards MF, van Gulik TM, de Wit LT , et al. Evaluation of morbidity and mortality after resection for hilar cholangiocarcinoma—a single center experience. Surgery 2000; 127(4):395-404. doi: 10.1067/msy.2000.104250. doi: 10.1067/msy.2000.104250 pmid: 10776430
56.	Sano T, Shimada K, Sakamoto Y , et al. One hundred two consecutive hepatobiliary resections for perihilar cholangiocarcinoma with zero mortality. Ann Surg 2006; 244(2):240-7. doi: 10.1097/01.sla.0000217605.66519.38. doi: 10.1097/01.sla.0000217605.66519.38 pmid: 16858186
57.	Schindl MJ, Redhead DN, Fearon KC , et al. The value of residual liver volume as a predictor of hepatic dysfunction and infection after major liver resection. Gut 2005; 54(2):289-96. doi: 10.1136/gut.2004.046524. doi: 10.1136/gut.2004.046524 pmid: 15647196

Surgical procedures	Bismuth and Corlette type of HC					Sub-total	R0 resection rate(%)
Surgical procedures	Type Ⅰ	Type Ⅱ	Type Ⅲa	Type Ⅲb	Type Ⅳ	Sub-total	R0 resection rate(%)
Hilar resection alone	8 (8)	7 (4)	2 (1)	3 (2)	6 (1)	26 (16)	61.5
Hilar resection + MLR						33 (19)	57.6
Left hemihepatectomy	0	0	0	7 (7)	6 (4)	13 (11)	84.6
Left trisectionectomy	0	0	0	2 (1)	5 (3)	7 (4)	57.1
Right hemihepatectomy	0	0	4 (1)	0	5 (0)	9 (1)	11.1
Right trisectionectomy	0	0	1 (1)	0	2 (2)	3 (3)	100.0
Central liver resection	0	0	0	0	1 (0)	1 (0)	0
Total	8 (8)	7 (4)	7 (3)	12 (10)	25 (10)	59 (35)	59.3

Postoperative outcomes	Hilar resection (n=26)	Hilar resection and MLR(n=33)	χ²	P value
Mortality (n, %)	1 (3.8 )	2 (6.1)	0.703*	0.145
Morbidity (n, %)	6 (23.1)	15 (45.5)	3.893	0.048
Biliary leak	1 (3.8)	11 (33.3)	7.804	0.005
Perihepatic abscess	0 (0)	2 (6.1)	1.603*	0.205
Liver failure	0 (0)	2 (6.1)	1.603*	0.205
Sepsis	1 (3.8)	2 (6.1)	0.703*	0.145
Pneumonia	1 (3.8)	2 (6.1)	0.703*	0.145
GI hemorrhage	0 (0)	1 (3.0)	0.788*	0.375
DEG	2 (7.7)	0 (0)	2.583*	0.108
Cardiac asthma	1 (3.8)	0 (0)	1.269*	0.260
Hepaticojejunostomy	0 (0)	2 (6.1)	1.603*	0.205
UG-TPPCD	0 (0)	6 (18.2 )	5.173*	0.023
Reoperation	0 (0)	3 (9.1 )	2.448*	0.118

Variables	1-year survival rate (n=50)	P / χ²_log-rank	3-year survival rate (n=44)	P / χ²_log-rank	5-year survival rate (n=31)	P / χ²_log-rank
Hepatic ischemia		0.738/0.112^#		0.910/0.013^#		0.402/0.703^#
Yes	50.0% (4)		25.0% (4)		33.3% (3)
No	58.7% (46)		22.5% (40)		14.3% (28)
Estimated blood loss		0.724/0.124		0.681/0.169^#		0.562/0.337^#
≥2000 ml	53.8% (13)		18.2% (11)		22.2% (9)
<2000 ml	59.5% (37)		24.2% (33)		13.6% (22)
Transfusion (units)		0.520/0.414^#		0.460/0.547^#		0.527/0.399^#
not applied	61.3% (31)		25.0% (28)		10.0% (20)
1 - 3	55.6% (9)		28.6% (7)		50.0% (4)
>3	50.0% (10)		11.1% (9)		14.3% (7)
Type of resection		0.111/2.538		0.819/0.052^#		0.803/0.062^#
Hilar resection+MLR	67.9% (28)		24.0% (25)		17.6% (17)
Hilar resection	45.5% (22)		21.1% (19)		14.3% (14)
Vascular resection		0.817/0.054^#		0.438/0.602^#		NA
Yes	50.0% (2)		0 (2)		0 (0)
No	53.3% (48)		23.8% (42)		16.1% (31)
Surgical margin status		0.059/3.577^#		0.104/2.702^#		0.036/4.375^#
R0	65.5% (29)		30.8% (26)		31.3% (16)
R1	60.0% (15)		14.3% (14)		0 (11)
R2	16.7% (6)		0 (4)		0 (4)

Variables	1-year survival rate (n=50)	P / χ²_log-rank	3-year survival rate (n=44)	P / χ²_log-rank	5-year survival rate (n=31)	P / χ²_log-rank
Histopathologic grade		0.925/0.009^#		0.010/6.690^#		0.014/6.069^#
Well	60.0% (5)		75.0% (4)		66.7% (3)
Moderate & poor	57.8% (45)		17.5% (40)		11.5% (26)
Perineural invasion		0.726/0.123		0.290/1.144^#		0.592/0.287^#
Yes	55.0% (20)		13.3% (15)		12.5% (8)
No	60.0% (30)		27.6% (29)		17.4% (23)
Hepatic invasion		0.084/2.993		0.290/1.144^#		0.889/0.020^#
Yes	41.2% (17)		13.3% (15)		16.7% (12)
No	66.7% (33)		27.6% (29)		15.8% (19)
Microvascular invasion		0.738/0.112		0.051/3.799^#		0.437/0.604^#
Yes	61.1% (18)		6.3% (16)		9.1% (11)
No	56.3% (32)		32.1% (28)		20.0% (20)
Lymph node metastases		0.075/3.178		0.025/4.998^#		0.272/1.209^#
Yes	42.1% (19)		5.6% (18)		6.7% (15)
No	67.7% (31)		34.6% (26)		25.0% (16)
AJCC staging		0.003/8.981^#		0.024/5.807^#		0.312/1.022^#
Ⅰ	78.6% (14)		38.5% (13)		22.2% (9)
Ⅱ	66.7% (9)		37.5% (8)		25.0% (4)
Ⅲ	63.2% (19)		11.8% (17)		15.4% (13)
Ⅳ	0 (8)		0 (6)		0 (5)

Factors	P value	Wald χ²	Hazard ratio	95% CI
Preoperative Ca19-9 (<1000 U/mL vs. ≥1000 U/mL)	<0.001	17.255	7.039	2.803-17.678
Histopathologic grade (well vs. moderate / poor)	0.044	4.068	4.964	1.046-23.552
Surgical margins (R0)	0.031	6.939	Reference	-
(R1)	0.292	1.113	2.051	0.254-1.509
(R2)	0.033	4.529	3.190	1.096-9.287
AJCC staging (Ⅰ)	0.015	10.459	Reference	-
(Ⅱ)	0.984	<0.001	0.988	0.314-3.113
(Ⅲ)	0.105	2.634	2.463	0.829-7.315
(Ⅳ)	0.004	8.239	7.091	1.861-27.017
CEA (<4.7 ng/mL vs. ≥4.7 ng/mL)	0.609	0.262	0.700	0.179-2.736
Lymph node metastasis (negative vs. positive)	0.862	0.030	1.078	0.464-2.505

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