Liver Transplantation as a New Standard of Care in Patients With Perihilar Cholangiocarcinoma? Results From an International Benchmark Study

Abstract

Objective: To define benchmark values for liver transplantation (LT) in patients with perihilar cholangiocarcinoma (PHC) enabling unbiased comparisons. Background: Transplantation for PHC is used with reluctance in many centers and even contraindicated in several countries. Although benchmark values for LT are available, there is a lack of specific data on LT performed for PHC. Methods: PHC patients considered for LT after Mayo-like protocol were analyzed in 17 reference centers in 2 continents over the recent 5-year period (2014)(2015)(2016)(2017)(2018). The minimum follow-up was 1 year. Benchmark patients were defined as operated at high-volume centers ( ≥ 50 overall LT/year) after neoadjuvant chemoradiotherapy, with a tumor diameter <3 cm, negative lymph nodes, and with the absence of relevant comorbidities. Benchmark cutoff values were derived from the 75th to 25th percentiles of the median values of all benchmark centers. Results: One hundred thirty-four consecutive patients underwent LT after completion of the neoadjuvant treatment. Of those, 89.6% qualified as benchmark cases. Benchmark cutoffs were 90-day mortality ≤ 5.2%; comprehensive complication index at 1 year of ≤ 33.7; grade ≥ 3 complication rates ≤ 66.7%. These values were better than benchmark values for other indications of LT. Five-year disease-free survival was largely superior compared with a matched group of nodal negative patients undergoing curative liver resection (n = 106) (62% vs 32%, P < 0.001). Conclusion: This multicenter benchmark study demonstrates that LT offers excellent outcomes with superior oncological results in early stage PHC patients, even in candidates for surgery. This provocative observation should lead to a change in available therapeutic algorithms for PHC.

Classification of Adverse Events in Adult Surgery

“…18 The research group of Clavien et al introduced the notion of global outcome benchmarks, where procedure-specific outcome goals are set for a list of clinically relevant quality indicators (QIs), based on the 75th percentile of the outcomes obtained in international high-volume centers. 11,13,[19][20][21][22][23][24][25][26][27][28][29][30][31][32] Global outcome benchmarks have been so far established for minimally invasive esophagectomy, 25 liver surgery, 26 liver transplantation, 24,31 ALPPS (associating liver partition and portal vein ligation for staged hepatectomy), 22 pancreatic surgery, 20,23 colorectal resections, 32 as well as for bariatric surgery 19,21 (►Table 1). Meanwhile, Kolfschoten et al developed a composite outcome measure representing the percentage of patients with textbook outcomes, meaning that all desired health outcomes are reached simultaneously.…”

Liver Transplantation for perihilar cholangiocarcinoma. Do we need to move forward?

“…The present review did not aim to compare survival in transplanted versus resected patients with pCCA since, once again, the heterogeneity among studies and inherent limitations in study design, comparisons, and data made it difficult to reach a conclusion about which approach is superior [60] .…”

Liver transplantation for perihilar cholangiocarcinoma is not a provocative idea

“…Both of the techniques mentioned have been well described by the Nagoya center and have showed a better R0 resection rate but also better long-term oncological outcomes ( 5 - 7 ). The results of the Nagoya center seem to stand out, not only in terms of oncological survival, but also in terms of postoperative morbidity and mortality ( 1 , 4 , 7 ). Contrary to what has been proposed in the debate following the present article [see response of Pierre-Alain Clavien to Antonio Pinna, p. 853 ( 1 )], rather than trending towards resection in some centers and towards transplantation in others, it is likely that a standardized resection technique should we followed.…”

“…Length of stay was 1.4 [1][2][3][4] days {median [interquartile range (IQR)]} in intensive care unit (ICU) and overall stay was 7 [6][7][8][9][10][11][12][13] days. Re-intervention rate was 63% and R0resection was achieved in 94% of cases.…”

“…This is a multicenter benchmarking study on liver transplantation (LT) for perihilar cholangiocarcinoma (PHC) after neoadjuvant chemoradiotherapy ( 1 ). The study comprises of 134 patients from 2014 to 2018 among whom the majority had underlying primary sclerosing cholangitis (PSC).…”