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

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.

Figures/Tables 8

Figure 1.

Table 1

Table 2

Table 3

Univariate analyses of patient-related risk factors for 1-,3-, and 5-year survival rates§"

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)

Table 3

Table 4

Table 5

Table 6

Figure 2.

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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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Postoperative Complications and Survival Analysis of Surgical Resection for Hilar Cholangiocarcinoma: A Retrospective Study of Fifty-Nine Consecutive Patients

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