Perihilar Cholangiocarcinoma – Novel Benchmark Values for Surgical and Oncological Outcomes From 24 Expert Centers

Abstract

Objective: The aim of this study was to define robust benchmark values for the surgical treatment of perihilar cholangiocarcinomas (PHC) to enable unbiased comparisons. Background: Despite ongoing efforts, postoperative mortality and morbidity remains high after complex liver surgery for PHC. Benchmark data of best achievable results in surgical PHC treatment are however still lacking. Methods: This study analyzed consecutive patients undergoing major liver surgery for PHC in 24 high-volume centers in 3 continents over the recent 5-year period (2014–2018) with a minimum follow-up of 1 year in each patient. Benchmark patients were those operated at high-volume centers (≥50 cases during the study period) without the need for vascular reconstruction due to tumor invasion, or the presence of significant co-morbidities such as severe obesity (body mass index ≥35), diabetes, or cardiovascular diseases. Benchmark cutoff values were derived from the 75th or 25th percentile of the median values of all benchmark centers. Results: Seven hundred eight (39%) of a total of 1829 consecutive patients qualified as benchmark cases. Benchmark cut-offs included: R0 resection ≥57%, postoperative liver failure (International Study Group of Liver Surgery): ≤35%; in-hospital and 3-month mortality rates ≤8% and ≤13%, respectively; 3-month grade 3 complications and the CCI: ≤70% and ≤30.5, respectively; bile leak-rate: ≤47% and 5-year overall survival of ≥39.7%. Centers operating mostly on complex cases disclosed better outcome including lower post-operative liver failure rates (4% vs 13%; P = 0.002). Centers from Asia disclosed better outcomes. Conclusion: Surgery for PHC remains associated with high morbidity and mortality with now the availability of benchmark values covering 21 outcome parameters, which may serve as key references for comparison in any future analyses of individuals, group of patients or centers.

Textbook outcome after major hepatectomy for perihilar cholangiocarcinoma — definitions and influencing factors

“…In recent years, the concept of the TO as a quality measure depicting the ideal surgical outcome has been used in complex oncological surgery, especially in the field of HBP surgery. A recently published multi-center study by Mueller et al has examined the outcome after PHC surgery for socalled benchmark cases [25]. This study marks an important milestone in the field of PHC surgery since it provides a definition of what is to be considered a benchmark case.…”

“…Median OS of all patients was 29 (24-35) months after resection, whereas DFS was 22 (17)(18)(19)(20)(21)(22)(23)(24)(25)(26) months. After excluding patients who died within 90 days after resection, no significant difference between the two groups in either OS (p=0.280) or DFS (p=0.735) analysis could be detected.…”

Robotic Surgery for Biliary Tract Cancer

“…Indeed, reported in a cohort of 440 patients with hilar CC, Nuzzo et al a morbidity rate of 47%, mortality rate of 10%, and an R0 resection rate of 77% [ 29 ]. Furthermore, the present pooled results for robotic surgery may be compared to the established international benchmark results published in 2021 [ 30 ]. Among the 708 cases of hilar CC qualifying as benchmark cases, the median operative time was 432 min, estimated blood loss was 852 mL, length of hospitalization was 16 days, rate all complications was 76%, rate of major complications 57%, in-hospital mortality was 3%, R0 rate was 57%, and lymph node retrieval was 4 nodes [ 30 ].…”

“…Furthermore, the present pooled results for robotic surgery may be compared to the established international benchmark results published in 2021 [ 30 ]. Among the 708 cases of hilar CC qualifying as benchmark cases, the median operative time was 432 min, estimated blood loss was 852 mL, length of hospitalization was 16 days, rate all complications was 76%, rate of major complications 57%, in-hospital mortality was 3%, R0 rate was 57%, and lymph node retrieval was 4 nodes [ 30 ]. Tang et al performed a meta-analysis of open vs. MIS surgery for hilar CC which included 9 studies (7 laparoscopic, 2 robotic) and revealed increased operative time and cost with MIS, but a decrease in blood loss, pain, and length of stay [ 31 ].…”

The Applications of 3D Imaging and Indocyanine Green Dye Fluorescence in Laparoscopic Liver Surgery

“…Given the ongoing debate in the literature, patients with HCC both undergo anatomical or Diagnostics 2021, 11, 2169 2 of 11 non-anatomical liver resections depending on centers and geographic areas of treatment, with different preoperative and surgical implications [5]. On the contrary, cholangiocarcinomas both intra-and extrahepatic, generally require liver resections associated with lymphadenectomy as these tumors has been associated with a higher chance of spreading to regional lymph node stations [6,7]. While intrahepatic cholangiocarcinomas normally require partial or anatomical resections to remove as much liver parenchyma as required to achieve a negative margin, patients with perihilar cholangiocarcinomas are generally scheduled for more extensive resections (i.e., major hepatectomies with bile ducts resection and reconstructions).…”