Postoperative Mortality after Liver Resection for Perihilar Cholangiocarcinoma: Development of a Risk Score and Importance of Biliary Drainage of the Future Liver Remnant

• Published in: Journal of the American College of Surgeons Vol. 223; no. 2; pp. 321 - 331.e1
• Main Authors: Wiggers, Jimme K., MD, PhD, Koerkamp, Bas Groot, MD, PhD, Cieslak, Kasia P., MD, Doussot, Alexandre, MD, van Klaveren, David, PhD, Allen, Peter J., MD, FACS, Besselink, Marc G., MD, PhD, Busch, Olivier R., MD, PhD, D’Angelica, Michael I., MD, FACS, DeMatteo, Ronald P., MD, FACS, Gouma, Dirk J., MD, PhD, Kingham, T Peter, MD, FACS, van Gulik, Thomas M., MD, PhD, Jarnagin, William R., MD, FACS
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.08.2016
• Subjects: Adult; Aged; Aged, 80 and over; Bile Duct Neoplasms - mortality; Bile Duct Neoplasms - surgery; Decision Support Techniques; Drainage; Female; Hepatectomy - methods; Hepatectomy - mortality; Hepatic Duct, Common - surgery; Humans; Klatskin Tumor - mortality; Klatskin Tumor - surgery; Logistic Models; Male; Middle Aged; Preoperative Care - methods; Preoperative Period; Retrospective Studies; Risk Assessment; Risk Factors; Surgery; Treatment Outcome; future liver remnant; volumetry; perihilar; risk score; prediction; postoperative mortality; cholangiocarcinoma; biliary drainage; PHC; FLR; MSKCC; AMC; AUC
• ISSN: 1072-7515; 1879-1190
• DOI: 10.1016/j.jamcollsurg.2016.03.035

Abstract Background Liver surgery for perihilar cholangiocarcinoma (PHC) is associated with postoperative mortality ranging from 5% to 18%. The aim of this study was to develop a preoperative risk score for postoperative mortality after liver resection for PHC, and to assess the effect of biliary drainage of the future liver remnant (FLR). Study design A consecutive series of 287 patients submitted to major liver resection for presumed PHC between 1997 and 2014 at two Western centers was analyzed; 228 patients (79%) underwent preoperative drainage for jaundice. FLR volumes were calculated with CT volumetry, and completeness of FLR drainage was assessed on imaging. Logistic regression was used to develop a mortality risk score. Results Postoperative mortality at 90-days was 14%, and was independently predicted by age (Odds ratio [OR] per 10 years 2.1), preoperative cholangitis (OR 4.1), FLR volume below 30% (OR 2.9), portal vein reconstruction (OR 2.3), and incomplete FLR drainage in patients with FLR volume below 50% (OR 2.8). The risk score showed good discrimination (AUC 0.75 after bootstrap validation), and ranking patients in tertiles identified three (low-intermediate-high) risk subgroups with predicted mortalities of 2%, 11%, and 37%. No postoperative mortality was observed in 33 undrained patients with FLR volumes above 50%, including 10 jaundiced patients (median bilirubin level 11 mg/dL). Conclusions The mortality risk score for patients with resectable PHC can be used for patient counseling and identification of modifiable risk factors, which include FLR volume, FLR drainage status, and preoperative cholangitis. We found no evidence to support preoperative biliary drainage in patients with an FLR volume above 50%.