Middle and distal bile duct carcinoma, retrospective analysis & short-term and long-term outcomes of surgical therapy

Česká verzia

Authors: P. Skalický ¹ ; J. Tesaříková ²; M. Gregořík ¹; K. Knápková ¹; H. Švébišová ³; D. Kurfúrstová ⁴; Dušan Klos ² ; M. Loveček ¹
Authors place of work: 1. chirurgická klinika Fakultní nemocnice Olomouc ¹; 1. chirurgická klinika Lékařské fakulty Univerzity Palackého v Olomouci ²; Onkologická klinika Fakultní nemocnice Olomouc ³; Ústav klinické a molekulární patologie Fakultní nemocnice Olomouc ⁴
Published in the journal: Rozhl. Chir., 2022, roč. 101, č. 9, s. 436-442.
Category: Original articles
doi: https://doi.org/10.33699/PIS.2022.101.9.436–442

Summary

Introduction: The prognosis of extrahepatic cholangiocarcinoma is dismal and the only way to achieve long-term survival is surgical resection. While pancreatoduodenectomy (PD) is the standard procedure for distal cholangiocarcinoma (distal bile duct cancer; DBDC), bile duct segmental resection (BDR) can be used as an alternative approach for middle bile duct cholangiocarcinoma (middle bile duct cancer; MBDC). The aim of the study was to calculate the short-term and long-term outcomes of curative-intent surgery in distal bile duct cholangiocarcinoma patients.

Methods: A retrospective cohort study of consecutive patients treated for MBDC and DBDC with PD or BDR between 1/2009–12/2019. The patients were divided according to the type of surgical resection (PD and BDR group). Demographic, clinicopathological and histopathological data and overall survival (OS) were evaluated in both groups. OS was estimated using the Kaplan-Meier analysis.

Results: The study comprised a total of 62 patients – 45 patients (72.6%) in the PD group and 17 (27.4%) in the BDR group. Patients undergoing BDR were significantly older than those receiving PD (p=0.048). Men predominated in the PD group (N=34/45; 75.6%) while more women were included in the BDR group (N=10/17; 58.8%). Median age was higher in the BDR group (p=0.048). Serious morbidity (Clavien-Dindo III–V) (33.3% vs 11.8%), 30-day and 90-day mortality (4.4% vs 0.0% and 8.9% vs 5.9%, respectively) predominated in the PD group although the differences were not statistically significant, as well as a longer hospital stay (16.0 days vs 11.0 days; p=0.002). Pathological assessments revealed comparable numbers of positive lymph nodes in both groups, but a significantly higher number of total resected lymph nodes in the PD group (p<0.0001). Similar OS rates at 1, 3 and 5 years were observed in both PD and BDR groups (66.7% vs 64.7%; 37.8% vs 47.0%; and 15.6% vs 17.6%, respectively).

Conclusion: Bile duct segmental resection (BDR) is an acceptable surgical modality for selected MBDC patients with lower morbidity and comparable survival compared to PD. In case of BDR negative bile duct resection margins need to be confirmed in the intraoperative period by frozen section examination.

Keywords:

pancreatoduodenectomy – bile duct resection – distal bile duct cancer – middle bile duct cancer

Zdroje

1. Everhart JE, Ruhl CE. Burden of digestive diseases in the United States part III: liver, biliary tract, and pancreas. Gastroenterology 2009;136:1134–1144. doi:10.1053/j. gastro.2009.02.038.

2. Balzano G, Zerbi A, Capretti G, et al. Effect of hospital volume on outcome of pancreaticoduodenectomy in Italy. Br J Surg. 2008;95:357–36. doi:10.1002/ bjs.5982.

3. Hartwig W, Hackert T, Hinz U, et al. Pancreatic cancer surgery in the new millennium: better prediction of outcome. Ann Surg. 2011;254:311–319. doi:10.1097/ SLA.0b013e31821fd334.

4. Pecorelli N, Balzano G, Capretti G, et al. Effect of surgeon volume on outcome following pancreaticoduodenectomy in a high-volume hospital. J Gastrointest Surg. 2012;16:518–523. doi:10.1007/ s11605-011-1777-2.

5. Wente MN, Bassi C, Dervenis C, et al. Delayed gastric emptying (DGE) after pancreatic surgery: A suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2007;142:761–768. doi:10.1016/j. surg.2007.05.005.

6. Wente MN, Veit JA, Bassi C, et al. Postpancreatectomy hemorrhage (PPH): An International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 2007;142:20–25. doi:10.1016/j. surg.2007.02.001.

7. Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery 2017;161:584–591. doi: 10.1016/j.surg.2016.11.014.

8. Morino K, Seo S, Yoh T, et al. The efficacy and limitations of postoperative adjuvant chemotherapy in patie,nts with extrahepatic cholangiocarcinoma. Anticancer Res. 2019 Apr;39(4):2155–2161. doi:10.21873/anticanres.13329.

9. Kapoor VK. Complications of pancreatoduodenectomy. Rozhl Chir. 2016;95:53– 59.

10. Bock EA, Hurtuk MG, Shoup M, et al. Late complications after pancreaticoduodenectomy with pancreaticogastrostomy. J Gastrointest Surg. 2012;16:914–919. doi:10.1007/s11605-011-1805-2.

11. Akita M, Ajiki T, Kimihiko U, et al. Benefits and limitations of middle bile duct segmental resekcion of extrahepatic cholangiocarcinoma. Hepatobiliary and Pancreatic Diseases International 2020;19:147– 152. doi: 10.1016/j.hbpd.2020.01.002.

12. Kim N, Lee H, Min SK, et al. Bile duct segmental resection versus pancreatoduodenectomy for middle and distal common bile duct cancer. Ann Surg Treat Res. 2018;94:240–246. doi:10.4174/ astr.2018.94.5.240.

13. Lee HG, Lee SH, Yoo DD, et al. Carcinoma of the middle bile duct: is bile duct segmental resection appropriate? World J Gastroenterol. 2009;15:5966–5971. doi:10.3748/wjg.15.5966.

14. Schreuder AM, Engelsman AF, Roessel S, et al. Treatment of mid-bile duct carcinoma: Local resection or pancreatoduodenectomy? European J of Surg Onco. 2019; 45:2180–2187. doi:10.1016/j. ejso.2019.06.032.

15. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–213. doi:10.1097/01. sla.0000133083.54934.ae.

16. Tol JA, Gouma DJ, Bassi C, et al. Definition of a standard lymphadenectomy in surgery for pancreatic ductal adenocarcinoma: a consensus statement by the International Study Group on Pancreatic Surgery (ISGPS). Surgery 2014;156(3):591– 600. doi:10.1016/j.surg.2014.06.016.

17. Japan Pancreas Society. Classification of pancreatic carcinoma. 4th English edition. Tokyo: Kanehara and Co. Ltd; 2017.

18. Cidon EU. Resectable cholangiocarcinoma: reviewing the role of adjuvant strategies. Clin Med Insights Oncol. 2016;10:43– 48. doi:10.4137/CMO.S32821.

19. DeOliveira ML, Schulick RD, Nimura Y, et al. New staging system and a registry for perihilar cholangiocarcinoma. Hepatology 2011;53:1363–1371. doi:10.1002/ hep.24227.

20. Farges O, Fuks D, Le Treut YP, et al. AJCC 7th edition of TNM staging accurately discriminates outcomes of patients with resectable intrahepatic cholangiocarcinoma: by the AFC-IHCC-2009 study group. Cancer 2010; 117:2170–2177. doi:10.1002/cncr.25712.

21. Nakanuma, Y., Tsutsui A, Ren XS, et al. Intrahepatic cholangiocarcinoma. International Agency for Research on Cancer [IARC]; Lyon: 2010:217–224. doi:10.1155/2014/805973.

22. Becker HD. Chirurgická onkologie. Praha, Grada Publishing 2005:396–399.

23. Skalický T, Třeška V, Šnajdauf J, et al. Hepato- pankreato-biliární chirurgie. Maxdorf 2011:288–298.

24. Skipworth JRA, Keane MG, Pereira SP. Update on the management of cholangiocarcinoma. Dig Dis. 2014;32(5):570–578. doi:10.1159/000360507.

25. Braga M, Capretti G, Pecorelli N, et al. A prognostic score to predict major complications after pancreaticoduodenectomy. Ann Surg. 2011;254:702–707. doi:10.1097/SLA.0b013e31823598fb.

26. Greenblatt DY, Kelly KJ, Rajamanickam V, et al. Preoperative factors predict perioperative morbidity and mortality after pancreaticoduodenectomy. Ann Surg Oncol. 2011;18:2126–2135. doi:10.1245/ s10434-011-1594-6.

27. Uzunoglu FG, Reeh M, Vettorazzi E, et al. Preoperative pancreatic resection (PREPARE) score. A prospective multicenter- based morbidity risk score. Annals of Surgery 2014;260(5):857–64. doi:10.1097/SLA.0000000000000946.

28. Loveček M, Skalický P, Köcher M, et al. Krvácení po pankreatektomii (PPH), prevalence, diagnostika a řešení. Rozhl Chir. 2016;95(9):350–357. PMID: 27653303.

29. Loveček M, Havlík R, Köcher M, et al. Wideochir Inne Tech Maloinwazyjne 2014;9(2):297–301. doi:10.5114/ wiitm.2011.38178.

30. Petrova E, Ruckert F, Zach S, et al. Survival outcome and prognostic factors after pancreatoduodenectomy for distal bile duct carcinoma: a retrospective multicenter study. Langenbeck‘s Arch Surg. 2017;402:831–840. doi:10.1007/s00423- 017-1590-9.

31. Byrling J, Andersson R, Sasor A, et al. Outcome and evaluation of prognostic factors after pancreaticoduodenectomy for distal cholangiocarcinoma. Ann of Gastroenterology 2017;30:571–517. doi:10.20524/aog.2017.0169.

32. Skalicky P, Urban O, Ehrmann J, et al. The short- and long-term outcomes of pancreatoduodenectomy for distal cholangiocarcinoma. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2021 Aug 10. doi:10.5507/bp.2021.043.

33. Lovecek M, Skalicky P, Klos D, et al. Longterm survival after resections for pancreatic ductal adenocarcinoma. Single centre experience. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2016;160(2):280–286. doi:10.5507/ bp.2016.011.

34. Wellner UF, Shen Y, Keck T, et al. The survival outcome and prognostic factors for distal cholangiocarcinoma following surgical resection: a meta-analysis for the 5-year survival. Surg Today 2017;47:271– 279. doi:10.1007/s00595-016-1362-0.

35. Shiraki T, Kuroda H, Takada A, et al. Intraoperative frozen section diagnosis of bile duct margin for extrahepatic cholangiocarcinoma. World J Gastroenterol 2018;24(12):1332–1342. doi:10.3748/wjg. v24.i12.1332.

36. Hajer J, Havlůj L, Whitley A, et al. The role of single-operator cholangioscopy (SpyGlass) in the intraoperative diagnosis of intraductal borders of cholangiocarcinoma proliferation – pilot study. Cas Lek Cesk. 2019;158(2):68–72. PMID: 31109166.

37. Miura F, Sano K, Amano H, et al. Evaluation of portal vein invasion of distal cholangiocarcinoma as borderline resectability. J Hepatobiliary Pancreat Sci. 2015;22:294–300. doi:10.1002/jhbp.198.

38. Maeta T, Ebata T, Hayashi E, et al. Nagoya Surgical Oncology Group. Pancreatoduodenectomy with portal vein resection for distal cholangiocarcinoma. Br J Surg. 2017;104:1549–1557. doi:10.1002/ bjs.10596.

39. Lin HP, Li SW, Liu Y, et al. Prognostic value of lymph nodes count on survival of patients with distal cholangiocarcinomas. World J Gastroenterol. 2018;24(9):1022– 1034. doi:10.3748/wjg.v24.i9.1022.

40. www.cancer.org.