Surgical procedure and prognosis of hilar cholangiocarcinoma

Hilar cholangiocarcinoma has a low radical resection rate and a poor long-term survival rate. In recent years, its prognosis has been improved with advancement of preoperative diagnostic techniques and surgical techniques. The aim of this study was to evaluate the prognostic factors of hilar cholangiocarcinoma and the relations of surgical procedure to the prognosis of the carcinoma.

A retrospective cohort study was done in 198 patients with hilar cholangiocarcinoma (117 men and 81 women, aged from 27 to 81 years), who had been admitted to this hospital from December 1997 to December 2002. Their symptoms were jaundice (94.5%), pruritus (56.6%) and abdominal pain (33.8%). Bismuth-Corlette classification showed type I in 14 patients, type II in 19, type IIIa in 12, type IIIb in 15, type IV in 112, and unclassifiable type in 26. 144 patients underwent laparotomy and others received bile drainage endoscopically (including endoscopic retrograde biliary drainage (ERBD) or endoscopic metal biliary endoprosthesis (EMBE) in 21 patients, endoscopic nose-biliary drainage (ENBD) in 31 or percutaneous transhepatic cholangiodrainage in 2. 120 patients (83.3%) received tumor resection including radical resection in 59 patients (41.0%). Twenty-three patients underwent paunched biliary exploration and drainage.

Cox's regression model analysis showed that occupation, preoperative total serum bilirubin level, operative procedure and postoperative adjuvant radiation were significantly related to postoperative survival rate in contrast to gender, age, choledocholithiasis, hepatitis, preoperative serum CA19-9 level, Bismuth-Corlette type, histopathologic grading and postoperative chemotherapy. The survival of patients in groups of biliary drainage, palliative resection and radical resection differed statistically and prolonged in a descending order. No statistical difference was found between ERBD or EMBE group and palliative resection group. So was between ERBD or EMBE group and biliary drainage group, or between ENBD group and biliary drainage group. The survival differed statistically between ERBD or EMBE group and ENBD group.

Operative procedure is the most important prognostic factor affecting the operative results of hilar cholangiocarcinoma. Radical resection is still the primary measure for a cure and long-term survival of the patients. For patients with irresectable hilar cholangiocarcinoma, no evidence has shown that the prognosis after treatment of ERBD or EMBE is poorer than that after laparotomy.