Preventing futile surgery in Intrahepatic and Perihilar cholangiocarcinomas: Can we identify preoperative factors to improve patient selection and optimize outcomes?

Intraoperative unresectability, postoperative deaths and early recurrences remain devastating futile events in the surgical management of Intrahepatic cholangiocarcinomas (iCCA) and Perihilar cholangiocarcinomas (pCCA). The present study aims to determine the preoperative predictors of futile surgery in cholangiocarcinomas. Consecutive hepatectomies for iCCA and pCCA, between September 2010 and June 2022 were included. Futility of surgery was defined as either intraoperative unresectability, postoperative 30-day mortality or recurrence within six months of surgery. Multivariable logistic regression was used to identify predictors of futility. One hundred and fifty patients of iCCA and pCCA underwent surgery during the time period. Thirty-seven (38.1 %) out of 97 patients of iCCA and 25(47.16 %) out of 53 patients of pCCA underwent futile resection. The predictive factors of futile surgery for iCCA were tumour number (≥2) (OR, 9.705; 95%CI, 2.378–39.614; p = 0.002), serum aspartate transaminase (OR, 8.31; 95%CI, 2.796–24.703; p 37 U/ml) (OR, 2.95; 95%CI, 1.051–8.283; p = 0.04). The predictive factors of futility for pCCA were lymph node involvement (OR, 7.636; 95%CI, 1.824–31.979; p = 0.005) and serum alkaline phosphatase (>562.5 U/L) (OR, 11.211; 95%CI, 1.752–71.750; p = 0.011). Futile surgery was observed in over one third of our patients. Five strong preoperative predictors of futility were identified. Careful analysis of these factors may reduce futile surgical explorations. •Intrahepatic (iCCA) and Perihilar cholangiocarcinomas (pCCA) are riddled with high rates of ‘open – close’ surgery, post-operative mortality, and early recurrences.•To avoid a futile surgery, preoperative case selection is of prime importance.•Futile surgery was encountered in over one-third of our patients of iCCA and pCCA undergoing surgery.•Predictors of futile surgery include multiple tumour nodules, high serum CA 19-9 and serum aspartate transaminase levels for iCCA and preoperative lymph node involvement and high serum alkaline phosphatase for pCCA.•These predictors serve as important markers to improve case selection and avoid a futile surgery.