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Standard portal vein resection (PVR) has been proposed to improve oncological outcomes in patients with perihilar cholangiocarcinoma (PHC), however it potentially introduces an increased risk of morbidity. The policy in Amsterdam UMC(AMC) is to resect the portal vein bifurcation selectively when involved, while in Charité-Universitätsmedizin Berlin, standard PVR is performed with right trisectionectomy. The objective of this study was to analyze postoperative outcomes and survival after standard or selective PVR for PHC. A retrospective study was performed including PHC-patients undergoing right-sided resection in Amsterdam (2000–2018) and Berlin (2005–2015). Primary outcomes were 90-day mortality, severe morbidity (Clavien-Dindo≥3), and overall survival (OS). A propensity score comparison (1:1 ratio) was performed corrected for age/sex/ASA/jaundice/tumor diameter/N-stage/Bismuth-Corlette type-IV. A total of 251 patients who underwent right-sided resection for PHC were evaluated: 87 in the selective (Amsterdam) and 164 in the standard PVR-group (Berlin). Major differences in baseline characteristics were observed, with higher ASA and AJCC-stage in the standard PVR-group (Berlin). Severe morbidity and 90-day mortality were comparable before matching (selective/Amsterdam:68% and 19%, standard/Berlin:61% and 17%, p = 0.284 and p = 0.746, respectively). After propensity score matching, both short term outcomes and OS were comparable (selective/Amsterdam (n = 45) 33 months (95%CI:20–45), standard/Berlin (n = 45) 31 months (95%CI:24–38, p = 0.747)). In this combined cohort, standard PVR was not associated with increased severe morbidity or mortality. After propensity score matching, survival was comparable after selective (Amsterdam) and standard PVR (Berlin). [ABSTRACT FROM AUTHOR]

Choledochoduodenostomy (CD) is believed to cause certain long-term complications, such as sump syndrome and reflux gastritis. Therefore, CD is considered inferior to a Roux-and-Y hepaticojejunostomy (HJ). The aim of this study was to compare short- and long-term outcomes following CD and HJ for benign biliary diseases. This was a retrospective, matched case-control study of patients undergoing biliary-digestive anastomosis for benign diseases between 2000 and 2016 in a tertiary centre. Patients undergoing CD and HJ were matched 1:1 based on age, sex, ASA-classification, indication, history of abdominal surgery or acute cholecystitis/pancreatitis. Short- and long-term outcomes were compared. Of 336 patients undergoing biliary-digestive anastomoses, 27 patients underwent CD. Matching resulted in two comparable groups of 26 patients each. Overall morbidity after HJ and CD was comparable: 30.8% versus 26.9% (p>0.999). Long-term complications occurred in 23.1% after HJ, and in 50% after CD (p=0.118). After CD, 2 patients (7.7%) developed sump syndrome. Both patients with an anastomotic stricture after HJ could be managed by endoscopic/radiological re-intervention, whilst all six patients with a stricture after CD required surgical re-intervention (p=0.016). Although short-term complications were comparable, the number of anastomotic strictures was higher in patients undergoing CD. We therefore conclude that HJ is the biliary bypass of choice while CD should be performed in selected patients only. [ABSTRACT FROM AUTHOR]

Morbidity and mortality after hepatectomy for perihilar cholangiocarcinoma are known to be high. However, reported postoperative outcomes vary, with notable differences between Western and Asian series. We aimed to determine morbidity and mortality rates after major hepatectomy in patients with perihilar cholangiocarcinoma and assess differences in outcome regarding geographic location and hospital volume. A systematic review was performed by searching the MEDLINE and EMBASE databases through November 20, 2017. Risk of bias was assessed and meta-analysis and metaregression were performed using a random effects model. A total of 51 studies were included, representing 4,634 patients. Pooled 30-day and 90-day mortality were 5% (95% CI 3%–6%) and 9% (95% CI 6%–12%), respectively. Pooled overall morbidity and severe morbidity were 57% (95% CI 50%–64%) and 40% (95% CI 34%–47%), respectively. Western studies compared with Asian studies had a significantly higher 30-day mortality, 90-day mortality, and overall morbidity: 8% versus 2% (P <.001), 12% versus 3% (P <.001), and 63% versus 54% (P =.048), respectively. This effect on mortality remained significant after correcting for hospital volume. Univariate metaregression analysis showed no influence of hospital volume on mortality or morbidity, but when corrected for geographic location, higher hospital volume was associated with higher severe morbidity (P =.039). Morbidity and mortality rates after major hepatectomy for perihilar cholangiocarcinoma are high. The Western series showed a higher mortality compared with the Asian series, even when corrected for hospital volume. Standardized reporting of outcomes is necessary. Underlying causes for differences in outcomes between Asian and Western centers, such as differences in treatment strategies, should be further analyzed. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the safety and efficacy of percutaneous or open irreversible electroporation (IRE) in a prospective cohort of patients with locally advanced, unresectable perihilar cholangiocarcinoma (PHC).Materials and Methods: In a multicenter Phase I/II study, patients with unresectable PHC due to extensive vascular involvement or N2 lymph node metastases or local recurrence after resection for PHC were included and treated by open or percutaneous IRE combined with palliative chemotherapy (current standard of care). The primary outcome was the number of major adverse events occurring within 90 d after IRE (grade ≥3), and the upper limit was predefined at 60%. Secondary outcomes included technical success rate, hospital stay, and overall survival (OS).Results: Twelve patients (mean age, 63 y ± 12) were treated with IRE. The major adverse event rate was 50% (6 of 12 patients), and no 90-d mortality was observed. All procedures were technically successful, with no intraprocedural adverse events requiring additional interventions. The median OS from diagnosis was 21 mos (95% confidence interval, 15-27 mos), with a 1-y survival rate of 75% after IRE.Conclusions: Percutaneous IRE in selected patients with locally advanced PHC seems feasible, with a major adverse event rate of 50%, which was below the predefined upper safety limit in this prospective study. Future comparative research exploring the efficacy of IRE is warranted. [ABSTRACT FROM AUTHOR]

Background: According to international guidelines, induction therapy may be considered in selected patients with initially unresectable locally advanced cholangiocarcinoma. The criteria for (un)resectability in cholangiocarcinoma varies between studies and no consensus-based agreement is available about these criteria. By performing a systematic literature review, we aimed to investigate the efficacy and safety of systemic induction therapy in initially unresectable locally advanced perihilar (pCCA) and intrahepatic cholangiocarcinoma (iCCA) and summarize resectability criteria used across studies.Methods: A literature search was performed in PubMed, EMBASE, Web of Science and Cochrane library to identify studies on systemic induction therapy in locally advanced pCCA and/or iCCA. The primary outcome was resection rate (RR) after induction therapy and secondary outcomes were overall survival (OS) and objective response rate (ORR).Results: Ten studies with a total of 1167 patients met the inclusion criteria and were included in this review. Among these patients, 334 (28.6%) were treated with systemic induction therapy. Across the studies, different types of chemotherapy regimens were administered (e.g., gemcitabine (based) chemotherapy and 5-FU (based) chemotherapy). Only six studies provided sufficient data and were used to analyze pooled (radical) resection rates. After induction therapy, 94 patients (39.2%) underwent a resection, of which R0 resections (22.9%). Pooled data on OS showed, better OS for chemotherapy plus resection versus chemotherapy only (pooled HR = 0.31, 95% CI = 0.19-0.50; P value < 0.0001).Conclusion: Adequately selected patients with locally advanced pCCA or iCCA may benefit from induction therapy followed by surgical resection. Prospective randomized controlled trials are warranted. [ABSTRACT FROM AUTHOR]

Outcomes for the four anatomical subtypes of biliary tract carcinoma (BTC) - intrahepatic, perihilar and distal cholangiocarcinoma (ICC, PHCC, DCC) and gallbladder carcinoma (GBC) - are often combined. However, large cohorts comparing short- and long-term outcomes for the anatomical subtypes of BTC are lacking. All patients who underwent resection for pathology proven ICC, PHCC, DCC or GBC (2000–2016) from a single Western high-volume center were retrospectively selected. Clinicopathological characteristics, short- and long-term outcomes were compared between the four anatomical subtypes. Overall, 361 patients with resected BTC were included (33 ICC, 135 PHCC, 148 DCC, 45 GBC). Clavien-Dindo grade III or higher complications were 48%, 51%, 36% and 8% (p < 0.001) and 90-day mortality was 9%, 15%, 3%, 4% (p < 0.001), for ICC, PHCC, DCC, GBC. Median overall survival was 37, 42, 29 and 41 months (p = 0.722), for ICC, PHCC, DCC, GBC. Five-year survival ranged between 29% and 37%. Anatomical subtype was not an independent predictor for overall survival. In this large single-center cohort of resected BTC, major morbidity and 90-day mortality varied between the four anatomical subtypes of BTC, mainly due to differences in surgical approach However, a significant difference in overall survival was not detected. [ABSTRACT FROM AUTHOR]

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. 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. 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. 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. [ABSTRACT FROM AUTHOR]