Treatment of mid-bile duct carcinoma: Local resection or pancreatoduodenectomy?

Whereas distal cholangiocarcinoma (DC) is treated by pancreatoduodenectomy (PD), consensus is lacking on treatment of mid-bile duct carcinoma (mid-BDC) without involvement of the pancreatic head. Both PD or a local resection (LR) of the extrahepatic bile duct with lymphadenectomy are being used. The aim of this study was to compare outcomes after PD and LR for mid-BDC and, for reference, PD for DC.

Retrospective monocenter study including consecutive patients who underwent LR for mid-BDC (LR), PD for mid-BDC (PD-mid) and PD for DC (PD-distal) between 2000 and 2016. Clinicopathologic characteristics, postoperative outcomes and survival were compared.

A total of 184 patients were included (LR, 22; PD-mid, 38; PD-distal, 124). Postoperative mortality was 0% following LR, 5% (2/22) for PD-mid and 3% (4/124) for PD-distal, p = 0.542. Major complications occurred in 5/22 patients (23%), 19/39 (50%) and 46/124 (37%) respectively, p = 0.103 (LR versus PD-mid, p = 0.038). Tumor size, differentiation grade and resection margin status were comparable across groups. Median number of resected lymph nodes was 5 (range 3-7), 9 (7-14) and 12 (8-16) respectively, p < 0.001. Median overall survival was 46 months (95%CI 10-82), 19 months. (95%CI 11-27), and 29 months (95%CI 23-35) respectively, p = 0.39 (LR versus PD-mid, p = 0.20). Disease-free survival also did not differ.

LR is an acceptable treatment for selected patients with mid-BDC, showing less morbidity and comparable survival despite smaller lymph node retrieval.