Approaches and Outcomes to Distal Cholangiocarcinoma

Comparative Outcomes of Minimally Invasive Versus Open Pancreatoduodenectomy in Distal Cholangiocarcinoma: A Systematic Review and Meta-Analysis

Pancreatoduodenectomy, the primary surgical strategy for managing cholangiocarcinoma, is executed via two distinct methodologies, namely minimally invasive pancreatoduodenectomy (MIPD) and open pancreatoduodenectomy (OPD). The selection between these surgical options is critical, as it directly influences patient outcomes, encompassing both short-term recovery metrics and long-term survival rates. Despite the clinical significance of these procedures, there exists a notable void in the literature regarding a comprehensive comparison of MIPD and OPD, particularly in assessing their respective efficacies and complications. This lack of detailed comparative analysis has left a gap in evidence-based guidance for clinicians faced with the decision of choosing the most appropriate surgical approach for their patients. The absence of robust data comparing the two techniques underscores the necessity for a meta-analysis that rigorously examines and contrasts the outcomes associated with MIPD and OPD. By drawing upon a wide array of international studies, this research aims to shed light on the advantages and potential drawbacks of each method, thereby providing a more informed basis for surgical decision-making in the treatment of cholangiocarcinoma.

Preoperative prognostic nutritional index predicts short-term complications after radical resection of distal cholangiocarcinoma

Background

The occurrence of postoperative complications of distal cholangiocarcinoma (dCCA) is an indicator of poor patient prognosis. This study aimed to determine the immune-nutritional indexes (INIs) that can predict short-term postoperative complications.

Methods

A retrospective analysis of 148 patients with dCCA who were operated radical pancreaticoduodenectomy at the First Hospital of Lanzhou University from December 2015 to March 2022 was conducted to assess the predictive value of preoperative INIs and preoperative laboratory tests for short-term postoperative complications, and a decision tree model was developed using classification and regression tree (CART) analysis to identify subgroups at risk for overall complications.

Results

In this study, 83 patients (56.08%) experienced overall complications. Clavien-Dindo grade III-V complications occurred in 20 patients (13.51%), and 2 patients died. The areas under curves (AUCs) of the preoperative prognostic nutritional index (PNI), controlling nutritional status (CONUT) score, and neutrophil-to-lymphocyte ratio (NLR) were compared; the PNI provided the maximum discrimination for complications (AUC = 0.685, 95% CI = 0.600-0.770), with an optimal cutoff value of 46.9, and the PNI ≤ 46.9 group had higher incidences of overall complications (70.67% vs. 40.00%, P < 0.001) and infectious complications (28.77% vs. 13.33%, P = 0.035). Multivariate logistic regression analysis identified PNI (OR = 0.87, 95% CI: 0.80-0.94) and total bilirubin (OR = 1.01, 95% CI: 1.00-1.01) were independent risk factors for overall complications (P < 0.05). According to CART analysis, PNI was the most important parameter, followed by the total bilirubin (TBIL) level. Patients with a PNI lower than the critical value and TBIL higher than the critical value had the highest overall complication rate (90.24%); the risk prediction model had an AUC of 0.714 (95% CI, 0.640-0.789) and could be used to stratify the risk of overall complications and predict grade I-II complications (P < 0.05).

Conclusion

The preoperative PNI is a good predictor for short-term complications after the radical resection of dCCA. The decision tree model makes PNI and TBIL easier to use in clinical practice.

Comparison of laparoscopic and open pancreaticoduodenectomy for the treatment of distal cholangiocarcinoma: A propensity score matching analysis

Background

There are few studies comparing the oncological outcomes of laparoscopic pancreaticoduodenectomy (LPD) and open pancreaticoduodenectomy (OPD) for distal cholangiocarcinoma (DCC). Our objective was to assess the short-term efficacy and long-term survival of LPD and OPD in patients with DCC.

Methods

The data of 124 DCC patients who underwent LPD or OPD at the Third Affiliated Hospital of Soochow University from May 2010 to May 2021 were retrospectively analyzed. Propensity score matching was performed to balance the two groups of baseline characteristics. After 1:1 matching, the overall survival (OS) of the two groups was compared by the Kaplan−Meier method. Univariate and multivariate Cox regression analyses were used to identify independent predictors of OS.

Results

The original cohort consisted of 124 patients. Nineteen patients were excluded because of incomplete baseline or follow-up data, and the remaining 105 patients were divided into two cohorts (45 in the LPD group and 60 in the OPD group). The LPD group showed more favorable results in OS analysis (LPD vs. OPD, 56.4 [46.2-66.5] vs. 48.9 [36.4-61.4], months, P=0. 01). PSM analysis identified 30 pairs of patients, and differences between matching groups were still significant (LPD vs. OPD, 67.9[58.2-77.6] vs. 47.4[31.4-67.5], months, P=0.002). Moreover, the LPD group experienced less intraoperative bleeding (LPD vs. OPD, 292.67 vs. 519.17 mL, P=0.002). Univariate analysis showed that surgical modality (P=0.012), carbohydrate antigen 19-9 (P=0.043), carcinoembryonic antigen (P=0.003), neutrophil-to-lymphocyte ratio (P=0.012), blood transfusion (P=0.031), clinically relevant postoperative pancreatic fistula (P&lt;0.001) and lymphatic metastasis (P=0.004) were predictors of OS. Multivariate Cox analysis demonstrated that carbohydrate antigen 19-9 (P=0.048), carcinoembryonic antigen (P=0.031) and lymphatic metastasis (P=0.023) were independent predictive factors of OS. However, adjuvant therapy had no significant effect on the OS of DCC patients after radical pancreaticoduodenectomy (P&gt;0.05).

Conclusions

For DCC patients, LPD may be a more recommended procedure because of its advantages over OPD in terms of intraoperative bleeding and long-term survival.

Surgical Treatment of Distal Cholangiocarcinoma

Distal cholangiocarcinoma (dCCA) is a rare malignancy arising from the epithelial cells of the distal biliary tract and has a poor prognosis. dCCA is often clinically silent and patients commonly present with locally advanced and/or distant disease. For patients identified with early stage, resectable disease, surgical resection with negative margins remains the only curative treatment strategy available. However, despite appropriate treatment and diligent surveillance, risk of recurrence remains high with nearly 50% of patients experiencing recurrence at 5 years subsequent to surgical resection; therefore, it is prudent to continue to optimize neoadjuvant and adjuvant therapies in order to reduce the risk of recurrence and improve overall survival. In this review, we discuss the clinical presentation, workup and surgical treatment of dCCA.

The impact of preoperative biliary drainage on postoperative outcomes in patients with malignant obstructive jaundice: a retrospective analysis of 290 consecutive cases at a single medical center

Background

The efficacy of preoperative biliary drainage (PBD) has been debated for several decades, and yet indications for PBD remain controversial. The aim of this study was to compare the postoperative morbidity and mortality in patients with malignant obstructive jaundice undergoing direct surgery versus surgery with PBD.

Methods

All consecutive patients with malignant obstructive jaundice who underwent radical resection between June 2017 and December 2019 at Zhongshan Hospital were analyzed retrospectively. The study population was divided into two groups: PBD group (PG) and direct surgery group (DG). The subgroups were chosen based on the site of obstruction. Perioperative indicators and postoperative complications were compared and analyzed.

Results

A total of 290 patients were analyzed. Postoperative complications occurred in 134 patients (46.4%). Patients in the PG group had a lower overall rate of postoperative complications compared with the DG group, with perioperative total bilirubin (TB) identified as an independent risk factor in multivariate analysis (hazard ratio = 1.004; 95% confidence interval 1.001–1.007; P = 0.017). Subgroup analysis showed that PBD reduced the complication rate in patients with proximal obstruction. In the proximal-obstruction subgroup, a preoperative TB level > 162 μmol/L predicted postoperative complications.

Conclusions

PBD may reduce the overall rate of postoperative complications among patients with proximal malignant obstructive jaundice.

Trial registration

ClinicalTrials.gov, 2018ZSLC 24. Registered May 17, 2018, https://clinicaltrials.gov/.

Comparison of postoperative complications and long-term oncological outcomes in minimally invasive versus open pancreatoduodenectomy for distal cholangiocarcinoma: A propensity score-matched analysis

BACKGROUND

Pancreatoduodenectomy (PD) is the only curative therapy for distal cholangiocarcinoma (dCC). There has been no study to compare outcomes between minimally invasive pancreatoduodenectomy (MIPD) and open pancreatoduodenectomy (OPD) for dCC. The aim of the study is to compare the two operation types for dCC in terms of postoperative and oncologic outcomes.

METHODS

Data from 426 patients who underwent MIPD (n = 91) or OPD (n = 335) for dCC from January 2012 to December 2019 at two tertiary hospitals were retrospectively reviewed. After 1:2 propensity score matching, postoperative and oncologic outcomes were compared.

RESULTS

Minimally invasive pancreatoduodenectomy group showed more favorable results than OPD group in terms of blood loss (MIPD vs OPD, 250 [150-400] vs 400 [200-600], mL, P < .001), and length of hospital stay (19.8 ± 11.3 vs 26.6 ± 14.3 days, P < .001). OPD group showed more favorable results than MIPD group in terms of operation time (MIPD vs OPD, 457 ± 70 vs 398 ± 85 min, P < .001) and harvested lymph nodes (14.9 ± 7.8 vs 20.7 ± 11.5, P < .001). There was no statistical difference between the two groups in the R0 resection rate and complications. In long-term survival analysis, there was no significant difference between the two groups.

CONCLUSION

Minimally invasive pancreatoduodenectomy showed comparable postoperative complications and long-term oncologic survival with OPD in the treatment of dCC.

Carbohydrate antigen 19-9 as a novel prognostic biomarker in distal cholangiocarcinoma

BACKGROUND

Distal cholangiocarcinoma (DCC) presents as one of the relatively rare malignant tumors in the digestive system and has a poor long-term prognosis. Curative resection is currently the most appropriate therapy for patients with DCC because of the lack of effective adjuvant therapies. Therefore, it is important to accurately predict the prognosis for formulating a reasonable treatment plan and avoiding unnecessary surgical trauma.

AIM

To minimize the interference of obstructive jaundice on carbohydrate antigen 19-9 (CA19-9) level by adapting CA19-9 to γ-glutamyltransferase (GGT) as an indicator, to determine the strong associations between CA19-9/GGT and postoperative neoplasm recurrence and long-term outcome of DCC.

METHODS

We enrolled 186 patients who were diagnosed with DCC between January 2010 and December 2019 and performed radical excision with strict criteria as follows in our hospital. Receiver operating characteristic curves were drawn according to preoperative CA19-9/GGT and 1-year survival. Based on this, patients were divided into two groups (group 1, low-ratio, n = 81; group 2, high-ratio, n = 105). Afterwards, by the way of univariate and multivariate analysis, the risk factors influencing postoperative tumor recrudesce and long-term prognosis of patients with DCC were screened out.

RESULTS

Optimum cut-off value of CA19-9/GGT was 0.12. Patients in group 2 represented higher CA19-9 and lymphatic metastasis rate accompanied by lower GGT, when compared with group 1 (P < 0.05). The 1-, 3- and 5-year overall survival rates of patients in groups 1 and 2 were 88.3%, 59.2% and 48.1%, and 61.0%, 13.6% and 13.6%, respectively (P = 0.000). Multivariate analysis indicated that CA19-9/GGT, lymphatic metastasis and tumor differentiation were independent risk factors for tumor recurrence and long-term prognosis of DCC.

CONCLUSION

Elevation of CA19-9/GGT performed better as a biomarker of aggressive carcinoma and predictor of poor clinical outcomes by reducing the effect of obstruction of biliary tract on CA19-9 concentration in patients with DCC.

The Impact of Intraoperative Frozen Section on Resection Margin Status and Survival of Patients Underwent Pancreatoduodenectomy for Distal Cholangiocarcinoma

Background

Intraoperative frozen section (FS) is broadly used during pancreaticoduodenectomy (PD) to ensure a negative margin status, but its survival benefits on obtaining a secondary R0 resection for distal cholangiocarcinoma (dCCA) is controversial and unclear.

Methods

Clinical data of 107 patients who underwent PD for dCCA was retrospectively collected and divided into different groups based on use of FS (FS and non-FS groups) and status of resection margin (pR0, sR0 and R1 groups), and clinical parameters and survival of patients were compared and analyzed accordingly.

Results

There were 50 patients in FS group with a median survival of 28 months, 57 patients in non-FS group with a median survival of 27 months. There was no statistical difference between the two groups with Kaplan-Meier survival analysis (P = 0.347). There were 98 patients in R0 group (88 in pR0 and 10 in sR0) and nine patients in R1 group, with a median survival of 29 months and 22 months respectively, which showed a better survival in R0 group than in R1 group (P = 0.006). Survival analyses between subgroups revealed difference between pR0 and R1 group (P = 0.005), while no statistical difference concerning pR0 vs. sR0 (P = 0.211) and sR0 vs. R1 groups (P = 0.262). Multivariate Cox regression analysis revealed resection margin status, pre-operative biliary drainage and lymph node invasion to be independent prognostic factors for dCCA patients.

Conclusions

Intraoperative FS should be recommended as it significantly increased the rate of R0 resection, which was positively related to a better survival. A primary R0 resection should also be encouraged and if not, a secondary R0 could be considered at the discretion of surgeons as it showed similar survival with primary R0 resection.

Long-term survival in patients with distal cholangiocarcinoma after pancreaticoduodenectomy combined with portal vein system resection and reconstruction

PURPOSE

Pancreaticoduodenectomy combined with portal vein resection for distal cholangiocarcinoma is rarely reported because it is a rare disease. We developed a program to evaluate the vascular invasion type, operation procedure, and long-term survival of distal cholangiocarcinoma patients with portal vein invasion.

METHODS

We retrospectively reviewed data for 123 distal cholangiocarcinoma patients after pancreaticoduodenectomy between January 2013 and December 2019. Portal vein system invasion was confirmed pathologically in 17 patients.

RESULTS

Multivariable Cox regression identified tumor differentiation degree, portal vein system invasion, and lymph node metastasis as independent risk factors affecting long-term survival. The 1- and 2-year overall survival rates for patients without and with portal vein system invasion were 79.7% and 58.9%, and 48.6% and 10.8%, respectively. Median overall survival in patients without and with portal vein system invasion was 33 months and 12 months, respectively.

CONCLUSION

Portal vein system invasion is an important independent risk factor affecting long-term survival in patients with distal cholangiocarcinoma. Pancreaticoduodenectomy combined with portal vein system resection and reconstruction did not increase the incidence of perioperative complications or mortality.

Neoadjuvant therapy for cholangiocarcinoma: A comprehensive literature review

Biliary tract cancers (BTCs) comprise a heterogenous group of aggressive and rare malignancies arising in the bile duct outside or within the liver. BTCs include cholangiocarcinoma (CCA), gallbladder cancer (GBC) and ampulla of Vater cancer (AVC); according to the "historical" anatomical classification, CCAs are further subdivided into extrahepatic cholangiocarcinomas (eCCAs) - including distal (dCCA) and perihilar (pCCA) - and intrahepatic cholangiocarcinomas (iCCA). Notably enough, these subtypes reflect distinct features in terms of biology, epidemiology, prognosis and therapeutic strategies. Although surgical resection remains the only potentially curative treatment option for CCA patients, radical surgery is possible for only a small proportion of cases. Moreover, it has been observed that up to 50% of patients deemed resectable at diagnosis are found to be unresectable during exploratory laparotomy. Additionally, even following radical surgery, recurrence rates are high. Neoadjuvant therapy represents an appealing approach in this setting, where this therapeutic strategy has the potential to improve local and distant control, to achieve R0 resection and to prevent distant metastasis. However, few data are currently available supporting neoadjuvant therapy in CCA and several questions remains unanswered, including the activity of systemic therapy in early stages of the disease, the optimal start time of treatment, patient selection and the length of neoadjuvant therapy. In this review, we will discuss available data on neoadjuvant systemic therapy in CCA, highlighting future directions in this setting, with a particular focus on recently published data and ongoing and recruiting trials.

Prognostic impact of lymph node parameters in distal cholangiocarcinoma after pancreaticoduodenectomy

Background

Pancreaticoduodenectomy is the only definitively curative therapy for the long-term survival of distal cholangiocarcinoma patients. Lymph node metastasis is widely accepted as an important prognostic factor for distal cholangiocarcinoma. The latest American Joint Committee on Cancer (AJCC) TNM classification system for distal cholangiocarcinoma has divided the lymph node metastasis patients into N1 and N2 by lymph node metastasis number. However, some studies suggested that the lymph node metastasis ratio may be better than the lymph node metastasis number. Therefore, we develop a program to analyze the correlation between lymph node parameters (lymph node dissection number, lymph node metastasis number, and lymph node metastasis rate) and long-term prognosis.

Methods

We retrospectively reviewed 123 distal cholangiocarcinoma patients after pancreatoduodenectomy from January 2011 to December 2019. The patients were grouped according to lymph node metastases and tumor-free and overall survival rates which were investigated with the Kaplan-Meier analysis. The logistic regression models were used for multivariate analysis to determine the risk factors for lymph node metastases. And the X-tile program was used to calculate the cutoff values for the lymph node parameters that discriminated survival.

Results

The 1-year, 3-year, and 5-year overall survival rates of patients with distal cholangiocarcinoma after pancreatoduodenectomy were 75.2%, 37.1%, and 31.5%, respectively. And the 1-year, 3-year, and 5-year overall survival rates of patients without and with lymph node metastasis were 83.0%, 50.7%, and 42.5% and 63.5%, 19.0%, and 19.0% (p = 0.000), respectively. Logistic regression showed CA19-9 and portal vein system invasion as independent risk factors for lymph node metastases. The receiver operating characteristic curve showed the optimal cutoff value of CA19-9 to predict the lymph node metastases was 75.5 U/mL. Determined by the X-tile software, the optimal cutoff values of the lymph node dissection number were 24 (p = 0.021), the lymph node metastasis number were 1 and 7 (p = 0.504), and the lymph node metastasis rate were 0.13 (p = 0.002).

Conclusion

Lymph node metastasis is an important factor affecting the long-term survival of distal cholangiocarcinoma patients.CA19-9 and portal vein system invasion are independent risk factors for lymph node metastasis. Besides, the lymph node dissection number and lymph node metastasis rate can predict the long-term survival better than lymph node metastasis number.

Proposal of the optimal numbers of examined and positive lymph nodes to the 8th edition of American Joint Committee on Cancer (AJCC) staging for 758 patients with distal cholangiocarcinoma

Introduction

The American Joint Committee on Cancer (AJCC) recommended retrieval of at least 12 lymph nodes and firstly classified N category by the number of positive lymph nodes (PLNs) for Distal Cholangiocarcinoma (DCC).

Objective

The end of this cohort study was to explore the optimal cut-off values of the number of examined lymph nodes (ELNs) and PLNs to better stratify patients by utilizing a population-based database.

Methods

A number of 758 patients with DCC from the Surveillance, Epidemiology, and End Results (SEER) database were enrolled in the study and comparing by the survival analysis.

Results

Survival analysis found that patients with ELNs < 5 had a lower 3-year disease-specific survival rate than ELNs ≥ 5 in N0M0 cohort (35.3% vs. 53.0%, P = 0.001) and in M0 cohort (42.7% vs. 32.8%, P = 0.006); survival curves between patients with ELNs < 12 and ELNs ≥ 12 were overlapped in N0M0 cohort (P = 0.256) and in M0 cohort (P = 0.233). Among patients with ELNs ≥ 5, using the optimal cut-off value of the number of PLNs (0, 2) could accurately stratify patients, but the recommendation of the number of PLNs (0, 3) by the AJCC could not.

Conclusions

This study recommended examining at least 5 lymph nodes and defining PLNs = 1–2 as the N1 category and PLNs ≥ 3 as the N2 category, which may better stratify distal cholangiocarcinoma patients and improve the accuracy of the eighth edition AJCC staging.