Parenchyma-preserving hepatectomy in the surgical treatment of hilar cholangiocarcinoma

Background: Although extended hepatic resection has been shown to improve p rognosis by increasing the surgical curability rate in hilar cholangiocarci noma, high surgical morbidity and mortality rates have been reported in pat ients with obstructive jaundice. Postoperative liver failure after hepatic resection in patients with obstructive jaundice has been shown to depend on the volume of the resected hepatic mass. The aim of this study was to eval uate the results of parenchyma-preserving hepatectomy in a surgical treatme nt for hilar cholangiocarcinoma. Study Design: Ninety-three resected patients with hilar cholangiocarcinoma were included in this retrospective study. The resected patients were strat ified into three groups: the extended hepatectomy (EXH) group (n = 66), the parenchyma-preserving hepatectomy (PPH) group (n = 14), and the local rese ction (LR) group (n = 13). The EXH group had undergone hepatectomy more ext ensive than hemihepatectomy, the PPH group had undergone hepatectomy less e xtensive than hemihepatectomy, and the LR group had undergone extrahepatic bile duct resection without hepatic resection. Surgical curability defined by histologically confirmed negative surgical margins, surgical morbidity a nd mortality, and survival rates were compared among the three groups. The clinicopathologic factors were studied for prognostic value by univariate a nd multivariate analyses. Results: Surgical curability of the PPH and EXH groups was better than that of the LR group. Fifty-four percent of patients in the LR group showed pos itive surgical margins at the hepatic stump of the bile duct, compared with 7% in the PPH group and 20% in the EXH groups (p < 0.01 for each compariso n). Surgical morbidity was higher in the EXH group (48%) than in the LR gro up (8%) and the PPH group (14%) (p < 0.01 and p < 0.05, respectively). Post operative hyperbilirubinemia occurred more frequently in the EXH group (29% ) than in the LR and PPH groups (0% and 0%, respectively, p < 0.05 for each comparison). Survival rates after resection were significantly higher in p atients who underwent hepatectomy, including PPH and EXH, than in patients who underwent LR, 29% versus 8% at 5 years, respectively (p < 0.05). But no significant difference in survival was found between the PPH and EXH group s. Univariate and multivariate analyses showed that significant prognostic factors for survival were resected margin, lymph nodal status, and vascular resection. Conclusions: In conclusion, PPH could obtain a curative resection and impro ve the outcomes for patients with hilar cholangiocarcinoma that is localize d at the hepatic duct confluence who do not require vascular resection. PPH might bring about a beneficial effect in highly selected patients accordin g to extent of cancer and high-risk patients with liver dysfunction. (J Am Coll Surg 1999;189:575-583. (C) 1999 by the American College of Surgeons).