title: Evolution of the surgical management of perihilar cholangiocarcinoma in a Western centre demonstrates improved survival with endoscopic biliary drainage and reduced use of blood transfusion.
abstract: BACKGROUND
  Perihilar cholangiocarcinoma (PHCCA) remains a surgical challenge for which few large Western series have been reported. The aims of this study were to investigate the results of surgical resection for PHCCA and assess how practice has evolved over the past 15 years.
  
  
  METHODS
  A prospectively maintained database was interrogated to identify all resections. Clinicopathological data were analysed for impact on survival. Subsequently, data for resections carried out during the periods 1994-1998, 1999-2003 and 2004-2008 were compared.
  
  
  RESULTS
  Eighty-three patients underwent resection. Trisectionectomy was required in 67% of resections. Overall survival was 70%, 36% and 20% at 1, 3 and 5 years, respectively. Size of tumour, margin (R0) status, lymph node status, distant metastasis, tumour grade, portal vein resection, microscopic direct vascular invasion, T-stage and blood transfusion requirement significantly affected outcome on univariate analysis. Distant metastasis (P = 0.040), percutaneous biliary drainage (P = 0.015) and blood transfusion requirement (P = 0.026) were significant factors on multivariate analysis. Survival outcomes improved and blood transfusion requirement was significantly reduced in the most recent time period.
  
  
  CONCLUSIONS
  Blood transfusion requirement and preoperative percutaneous biliary drainage were identified as independent indicators of a poor prognosis following resection of PHCCA. Longterm survival can be achieved following the aggressive surgical resection of this tumour, but the emergence of a clear learning curve in our analyses indicates that these patients should be managed in high-volume centres in order to achieve improved outcomes.
authors.affiliation: Department of Hepatobiliary and Transplant Surgery, St James's University Hospital, Leeds, UK.
authors.forename: Alastair L
authors.initials: AL
authors.lastname: Young
authors.forename: Tsuyoshi
authors.initials: T
authors.lastname: Igami
authors.forename: Yoshiki
authors.initials: Y
authors.lastname: Senda
authors.forename: Robert
authors.initials: R
authors.lastname: Adair
authors.forename: Shahid
authors.initials: S
authors.lastname: Farid
authors.forename: Giles J
authors.initials: GJ
authors.lastname: Toogood
authors.forename: K Rajendra
authors.initials: KR
authors.lastname: Prasad
authors.forename: J Peter A
authors.initials: JP
authors.lastname: Lodge
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001650:Bile Duct Neoplasms / Q000401:mortality / Q000601:surgery*; D001653:Bile Ducts, Intrahepatic / Q000601:surgery*; D001803:Blood Transfusion; D018281:Cholangiocarcinoma / Q000401:mortality / Q000601:surgery*; D016208:Databases, Factual; D004322:Drainage / Q000379:methods; D016145:Endoscopy, Digestive System; D005260:Female; D006801:Humans; D018285:Klatskin Tumor / Q000401:mortality / Q000556:secondary*; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D015996:Survival Rate; D016896:Treatment Outcome