Hepatopancreatoduodenectomy –a controversial treatment for bile duct and gallbladder cancer from a European perspective

Abstract

Background: Hepatopancreatoduodenectomy (HPD) is an aggressive operation for treatment of advanced bile duct and gallbladder cancer associated with high perioperative morbidity and mortality, and uncertain oncological benefit in terms of survival. Few reports on HPD from Western centers exist.The purpose of this study was to evaluate safety and efficacy for HPD in European centers.Method: Members of the European-African HepatoPancreatoBiliary Association were invited to report all consecutive patients operated with HPD for bile duct or gallbladder cancer between January 2003 and January 2018. The patient and tumor characteristics, perioperative and survival outcomes were analyzed. Results: In total, 66 patients from 19 European centers were included in the analysis. 90-day mortality rate was 17% and 13% for bile duct and gallbladder cancer respectively. All factors predictive of perioperative mortality were patient and disease-specific. The three-year overall survival excluding 90-day mortality was 80% for bile duct and 30% for gallbladder cancer (P = 0.013). In multivariable analysis R0-resection had a significant impact on overall survival. Conclusion:HPD, although being associated with substantial perioperative mortality, can offer a survival benefit in patient subgroups with bile duct cancer and gallbladder cancer. To achieve negative resection margins is paramount for an improved survival outcome.

Current role of hepatopancreatoduodenectomy for the management of gallbladder cancer and extrahepatic cholangiocarcinoma: A systematic review

“…In the majority of cases, HPD includes a major hepatic resection (at least three Coinaud’s segments), being right hepatectomy with simultaneous PD the most common combination in HPD[ 1 , 8 , 15 ]. Usually, also the segment I is included in the liver resection during HPD in order to increase the rate of R0 resection, especially in cases of ECC of Bismuth-Corlette type III–IV extending to the pancreato-duodenum, since the caudate lobe is involved by tumour[ 3 , 10 ]. Segmental hepatic resection or metastasectomy associated to PD (like in cases of PD for neuroendocrine tumours with limited hepatic metastases), or PD associated to hepatic resection without extirpation of the hilar bile duct (like in cases of GC with retropancreatic lymph node involvement) should not be considered as pure HPD.…”

“…In fact, genuine HPD consists in removal of the entire extrahepatic biliary system with the adjacent liver and the pancreatoduodenum [ 1 ]. Also a two-stage procedure in which the pancreatic and liver resections were performed at two different occasions not separated more than 2 months in time, can be barely defined as pure HPD[ 10 ].…”

“…The results of a recent meta-analysis demonstrated that PD plus venous resection has inferior survival outcomes and higher 30-d mortality when compared with standard PD, nonetheless that operation can obtain better survival outcomes when compared to nonoperative treatments in patients with portal-mesenteric invasion from pancreatic head adenocarcinoma[ 19 ]. For extension, venous resection has been used when necessary also during HPD[ 10 , 14 ]. On the other hand, the role arterial resection in surgical treatment of pancreatic and bile duct cancer remains controversial, although the prognostic value of hepatectomy with simultaneous resections of the portal vein and hepatic artery in patients with advanced ECC has been reported by some authors[ 2 ].…”

Surgical Therapy for Perihilar Cholangiocarcinoma: State of the Art

“…These studies describe a similar OS after additional resection of the proximal and distal resection planes as after initial R0 resections. If additional pylorus-preserving pancreaticoduodenectomy needs to be performed the OS is similar, but the perioperative mortality rate increases towards 17% [44, 49]. In addition, an intraoperative switch to additional pylorus-preserving pancreaticoduodenectomy is associated with a worse recurrence-free survival [50].…”

Prognostic implication of high grade biliary intraepithelial neoplasia in bile duct resection margins in patients with resected perihilar cholangiocarcinoma

“…Considering this high mortality, we think that HG BilIN margins should not be included as indications for HPD. 16 According to a review article by Ebata et al, the indications for HPD are when the margin is R1 after additional resection, not HG BilIN, and if the patients do not have other factors such as nodal metastases. This also indirectly supports that HG BilIN margins do not necessarily require HPD.…”