Portal vein reconstruction reduces textbook outcome achievement following radical resection for hilar cholangiocarcinoma

TL;DR

Portal vein reconstruction during surgery for a type of bile duct cancer reduces the chances of achieving ideal surgical outcomes and worsens long-term survival.

Contribution

This study identifies portal vein reconstruction as an independent negative predictor of textbook surgical outcomes in hilar cholangiocarcinoma patients.

Findings

Only 20.97% of patients with portal vein reconstruction achieved textbook outcomes, compared to 39.22% without it.

Patients with portal vein reconstruction had higher rates of post-operative complications like infection, bile leakage, and liver failure.

Portal vein reconstruction was linked to worse overall and relapse-free survival in long-term follow-up.

Abstract

Hilar cholangiocarcinoma (HCCA) remains a surgically challenging malignancy, often requiring major hepatectomy with vascular resection and reconstruction to achieve R0 resection. Portal vein reconstruction (PVR) enables radical resection in patients with vascular invasion, while its impact on surgical quality, measured using textbook outcome (TO), remains unclear.

A total of 317 HCCA patients who underwent R0 resection at a single tertiary medical center were retrospectively analyzed. In this study, TO was defined as the absence of 90-day mortality, readmission within 90 days, post-operative severe comorbidities, post-operative bile leak, post-operative liver failure, and intraoperative severe incidents. Epidemiological characteristics, pre-operative examination results, intraoperative features, post-operative comorbidities, and survival were compared between the PVR (n = 62) and non-PVR (n = 255) groups. The predictors of TO were evaluated using univariate and multivariate logistic regression analyses. The Kaplan–Meier curves were used to assess overall survival (OS) and relapse-free survival (RFS).

In this study, 113 of 317 patients (35.65%) achieved TO. TO rates were significantly lower in the PVR group (20.97%) compared with the non-PVR group (39.22%, p = 0.007). Patients with PVR had higher rates of post-operative infection (73.8% vs. 53.6%, p = 0.004), bile leakage (32.8% vs. 13.5%, p < 0.001), and liver failure (8.2% vs. 2.0%, p = 0.038). After univariate and multivariate analyses, PVR was identified as an independent negative predictor of TO (OR = 0.48, p = 0.046). Furthermore, the Kaplan–Meier analysis indicated significantly worse OS and RFS in both the non-TO and PVR groups (all p < 0.001).

PVR is significantly associated with reduced TO achievement and impaired long-term outcomes following R0 resection for HCCA patients. Although PVR remains a necessary approach to achieve curative resection in advanced cases, its impact highlights the need for careful patient selection and optimization of peri-operative management to improve the clinical outcomes of these patients.

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