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One hundred seven patients with hilar cholangiocarcinoma (76 men, 31 women; mean age 63 years [range 36 to 79 years]) were admitted to the hepatopancreatobiliary surgery unit of the National Cancer Center Hospital, Tokyo, from 1980 to 1997. Cholangiocarcinoma was defined as cancer originating in the upper common, right, or left hepatic duct. Tumors involving the hepatic hilar region but predominantly located in the hepatic parenchyma or the gallbladder were excluded.
The treatment strategy was as follows. Initially, the location and extent of the disease were roughly evaluated by ultrasonography, computed tomography, or both. Patients with distant metastases, ascites, and extensive nodal involvement were excluded as candidates for definitive surgery, except for those with a small number of metastatic foci in the resecting liver. In patients with obstructive jaundice, biliary decompression was established principally using ultrasonographically guided percutaneous transhepatic bile drainage, 41 and cholangiograms were obtained to assess the proximal end of the obstruction. The distal end was evaluated with endoscopic retrograde cholangiopancreatography. While waiting for jaundice to disappear, further investigation was carried out using angiography and thin-slice or helical computed tomography with a bolus injection of a contrast medium to obtain detailed information about local extension of the disease. To decrease the risk of postoperative liver insufficiency, preoperative portal embolization was performed in patients who were candidates for major hepatectomies in which >60% of the liver parenchyma was to be resected. Resectional surgery was planned 2 to 3 weeks after portal embolization. All attempts at definitive surgery were carried out when the serum level of total bilirubin decreased to <5 mg/dl.
Our standard resectional procedures consisted of hepatectomy, resection of the extrahepatic bile duct, and dissection of the regional lymph nodes. The following terms were used to describe the extent of hepatectomy—right or left hepatectomy: hemihepatic resection; left trisegmentectomy: left hepatectomy combined with resection of Couinaud segments V and VIII 43; extended right or left hepatectomy: hepatectomies more extended than hemihepatic resection and less extended than trisegmentectomy. Major hepatectomy, in which more than a hemihepatic lobe was resected, was commonly employed. However, either the extent of hepatic resection was restricted to include only the hilar region or no hepatectomy was performed when the patient had profound hepatic dysfunction or was in poor general condition. The hepatic lobe to be resected was principally determined according to the predominant site of the lesion. Extended right hepatectomy including resection of the entire caudate lobe and the inferior part of the left medial segment was carried out when the dominant site of involvement was the right hepatic or upper common bile duct. Extended left hepatectomy including resection of the spigelian lobe and the right hilar region was performed in patients in whom the left hepatic duct was predominantly involved. Lymph nodes and connective tissue in the hepatoduodenal ligament, posterior to the upper portion of the pancreatic head, and around the common hepatic artery were dissected in an en bloc fashion.
Every cut end of the bile duct was submitted for frozen-section examination. If the tissue was positive for cancer cells, an additional resection in an attempt to secure a clear margin was carried out whenever technically possible. Concomitant pancreatoduodenectomy was performed only when the microscopic spread of cancer cells into the intrapancreatic bile duct was the single obstacle to curative resection.
In preparing sections of a fixed specimen, surgeons assisted pathologists for the correct identification of complicated resectional margins. Three pathologists confirmed each histologic judgment. TNM categories and stage of disease were classified according to the criteria of the International Union Against Cancer (fifth edition).
Values are expressed as mean ± SD. The relations among categorical variables were tested with chi square analysis. Survival rate was estimated using the Kaplan-Meier method, including deaths from all causes. Univariate comparisons of survival curves were made with the log-rank test. Associations were considered significant if p ≤ 0.05. All the variables that were significantly associated with patient survival were included in a subsequent stepwise multivariate analysis. The Cox proportional hazard model with a likelihood ratio test was used for this purpose. Variables were eliminated from the model when significance exceeded 0.05 in a likelihood ratio test. In comparing the effect of nodal involvement, lymph nodes in the hepatoduodenal ligament, posterior to the upper half of the pancreatic head, and around the common hepatic artery were considered regional.