title: Additional resection of an intraoperative margin-positive proximal bile duct improves survival in patients with hilar cholangiocarcinoma.
abstract: OBJECTIVE
  To assess the survival benefit of additional resection of an intraoperative positive proximal bile duct margin (BD(Marg)) in patients undergoing hepatectomy for hilar cholangiocarcinoma (HCCA).
  
  
  BACKGROUND
  Intraoperative evidence of invasive cancer at the proximal (BD(Marg)) is associated with a dismal survival irrespective of whether a final negative (BD(Marg)) is achieved with an additional resection.
  
  
  METHODS
  Clinicopathologic, operative, and survival data of consecutive patients undergone curative intent hepatectomy with bile duct resection (n = 75) for HCC (1989-2010) were analyzed.
  
  
  RESULTS
  Frozen-section examination of the proximal (BD(Marg)) revealed invasive cancer in 19 of the 67 patients. After additional resection, which was possible in 18 cases, a secondary R0 (BD(Marg)) resection was achieved in 15 patients (83.3%), with 2 of these having, at final pathology, positive radial and distal margins. Eventually, 8 patients were classified as R1 and 67 as R0 (54 primary R0 and 13 secondary R0). Median survival of patients who had a secondary R0 resection (30.6 months) was similar to that of primarily R0-resected patients (29.3 months) and significantly better than that of R1 patients (14.9 months) (P = 0.026). Median time to recurrence and site of recurrence were similar in R0 patients independently of the performance of an additional resection. The incidence of biliary fistula was significantly increased (44.4% vs 17.5%; P = 0.02) in patients necessitating a margin re-resection.
  
  
  CONCLUSIONS
  Additional resection of a positive proximal (BD(Marg)) , albeit associated with an increased risk of biliary fistula, offers a significant survival benefit and should be attempted whenever possible.
authors: Division of Hepato-Biliary-Pancreatic and Digestive Surgery, Ospedale Mauriziano Umberto I, Torino, Italy. dribero@mauriziano.it
authors: Dario
authors: D
authors: Ribero
authors: Marco
authors: M
authors: Amisano
authors: Roberto
authors: R
authors: Lo Tesoriere
authors: Stefano
authors: S
authors: Rosso
authors: Alessandro
authors: A
authors: Ferrero
authors: Lorenzo
authors: L
authors: Capussotti
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001650:Bile Duct Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D001653:Bile Ducts, Intrahepatic / Q000473:pathology / Q000601:surgery*; D018281:Cholangiocarcinoma / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D005260:Female; D005629:Frozen Sections; D006498:Hepatectomy; D006801:Humans; D007432:Intraoperative Period; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D016019:Survival Analysis