title: Cholangiocarcinoma: are North American surgical outcomes optimal?
abstract: BACKGROUND
  Cholangiocarcinomas are deadly and require complex decisions as well as major surgery. A few referral centers have reported good results, but no robust, risk-adjusted outcomes data are available. The aims of this study were to analyze the surgical outcomes of a very large cohort of patients undergoing operations for cholangiocarcinoma in North America.
  
  
  METHODS
  The American College of Surgeons National Surgical Quality Improvement Program Participant Use File was queried for patients with bile duct cancers. Patients (n = 839) were classified as having intrahepatic (36.5%), perihilar (34.4%), or distal (29.1%) cholangiocarcinomas by the type of procedure performed. Observed and expected (O/E) morbidity and mortality rates, O/E indices, and regression-adjusted risk factors were determined.
  
  
  RESULTS
  Mortality was highest for perihilar tumors that were managed with hepatectomy and biliary-enteric anastomosis (11.9%) and lowest for distal cholangiocarcinomas (1.2%). After risk adjustment, mortality was considerable greater than expected for patients undergoing hepatectomy with biliary-enteric anastomosis (O/E = 3.0) or hepatectomy alone (O/E = 2.4).
  
  
  CONCLUSIONS
  This analysis suggests that postoperative outcomes are best for distal and worst for perihilar cholangiocarcinomas, and hepatectomy for bile duct cancers is associated with a 2- to 3-fold mortality risk. We conclude that North American surgical outcomes can be improved for patients with proximal cholangiocarcinomas.
authors.affiliation: Department of Surgery, Indiana University, Indianapolis, IN 46202, USA.
authors.forename: Andrew P
authors.initials: AP
authors.lastname: Loehrer
authors.forename: Michael G
authors.initials: MG
authors.lastname: House
authors.forename: Attila
authors.initials: A
authors.lastname: Nakeeb
authors.forename: E Molly
authors.initials: EM
authors.lastname: Kilbane
authors.forename: Henry A
authors.initials: HA
authors.lastname: Pitt
mesh_terms: D000368:Aged; D000714:Anastomosis, Surgical; D001650:Bile Duct Neoplasms / Q000401:mortality / Q000601:surgery*; D018281:Cholangiocarcinoma / Q000401:mortality / Q000601:surgery*; D005260:Female; D006498:Hepatectomy; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009656:North America / Q000453:epidemiology; D017063:Outcome Assessment, Health Care; D012307:Risk Factors