title: Is parenchyma-preserving hepatectomy a noble option in the surgical treatment for high-risk patients with hilar bile duct cancer?
abstract: BACKGROUND
  The essential minimum of hepatic segmentectomy combined with caudate lobectomy (parenchyma-preserving hepatectomy) has been recommended particularly for high-risk patients with hilar bile duct cancer to minimize the risk of postoperative liver failure. This quality control study investigated whether parenchyma-preserving hepatectomy is a "noble option" in the surgical treatment of hilar bile duct cancer.
  
  
  METHODS
  A total of 53 patients with hilar bile duct cancer underwent surgical resection. These patients were retrospectively classified into a major hepatectomy group (major Hx, n=30), a parenchyma-preserving hepatectomy group (preserving Hx, n=11), and a hilar bile duct resection group (HBDR, n=12). A preserving Hx consisted of caudate lobectomy, either alone (n=3), or combined with resection of segment 4 (S4, n=4), or S58 (n=3) or S458 (n=1). The preserving Hx was used for high-risk patients in whom tumor tissue was diagnosed to be Bismuth type I and II by preoperative selective percutaneous transhepatic cholangiography.
  
  
  RESULTS
  The mean numbers of hepatico-jejunostomies were 2.8, 4.8, and 4.6 in the respective groups. Mortality rates including hospital death were 13.3%, 0%, and 0% respectively. Morbidity rates were 46.7%, 54.5%, and 33.3%. The preserving Hx group encountered no liver failure (T.Bil>10 mg/dl, encephalopathy) but acquired hyperbilirubinemia (T.Bil>5 mg/dl), pulmonary insufficiency and other complications at the same frequency as in the major Hx group. The survival rates in the three groups were 35.6%, 52.5%, and 48.6% at 3 years and 25.2%, 14.9%, and 24.3% at 5 years respectively. Curability rates (R0 to R1+2) were 76.7%, 54.5% and 50.0%, respectively. Preserving Hx tended to result in higher frequencies of positive transmural margins (e.g., cancer cells remaining around the right hepatic artery or the portal vein).
  
  
  CONCLUSIONS
  Preserving hepatectomy for high-risk patients should be limited strictly to patients who do not have tumors which are not invading adjacent organs (e.g., T2) nor a segmental duct and are confined longitudinally to the right or the left.
authors.affiliation: Department of Surgery II, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan. hs440312@med.yokohama-cu.ac.jp
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Shimada
authors.forename: Itaru
authors.initials: I
authors.lastname: Endo
authors.forename: Mitsutaka
authors.initials: M
authors.lastname: Sugita
authors.forename: Hideki
authors.initials: H
authors.lastname: Masunari
authors.forename: Yoshiro
authors.initials: Y
authors.lastname: Fujii
authors.forename: Kuniya
authors.initials: K
authors.lastname: Tanaka
authors.forename: Hitoshi
authors.initials: H
authors.lastname: Sekido
authors.forename: Shinji
authors.initials: S
authors.lastname: Togo
mesh_terms: D000230:Adenocarcinoma / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D001650:Bile Duct Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D004621:Embolization, Therapeutic; D005260:Female; D006498:Hepatectomy / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D007582:Jejunostomy; D017093:Liver Failure / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D016577:Pancreaticoduodenectomy; D011786:Quality Control; D016019:Survival Analysis