Surgical treatment of hilar cholangiocarcinoma in the “new era”: the Nagoya University experience

Objective To review our surgical experience with hilar cholangiocarcinoma in the “new era.” Methods The medical records of 428 patients with hilar cholangiocarcinoma who underwent treatment between 2001 and 2008 at the First Department of Surgery, the Nagoya University Hospital, were retrospectively reviewed. Results Of the 428 patients, 298 (70%) underwent surgical resection (R0, n = 220; R1, n = 70; R2, n = 8). Portal vein resection was performed in 111 (37%) patients, and hepatic artery resection was performed in 53 (18%) patients. Several different types of postoperative complications occurred in a total of 129 (43%) patients and led to 6 (2%) deaths. Of the 298 resected tumors, 206 (69%) were extrahepatic type tumors, and the remaining 92 (31%) were intrahepatic type tumors. Using the Bismuth classification criteria, we identified 15 (5%) type I, 21 (7%) type II, 120 (40%) type III, and 142 (48%) type IV tumors. The overall 1-, 3-, and 5-year survival rates for all 298 patients were 77, 49, and 42%, respectively. The survival rates were highest among the 197 patients with pM0 disease who underwent R0 resection. Patients in this subgroup had a 5-year survival rate of 52%. The 5-year overall survival rate for the 55 patients with pM0 disease who underwent R1 resection was 32%. The survival rate for patients who had pM1 disease and/or underwent R2 resection was the worst of all the subgroups, but was nonetheless significantly better than that of patients with unresectable tumors. The survival rate for patients who underwent vascular resection and reconstruction was unexpectedly better, with 5-year survival of >20%. Conclusions The surgical approach to hilar cholangiocarcinoma has become more challenging in the new era. Nevertheless, surgical outcomes have been improved, with decreased morbidity and mortality rates being observed. Long-term survival has also steadily improved. These findings indicate that biliary surgeons should use an aggressive surgical strategy to treat this intractable disease.