title: Delay in surgical treatment of patients with hilar cholangiocarcinoma: does time impact outcomes?
abstract: BACKGROUND
  Substantial time elapses before patients with hilar cholangiocarcinoma (HCC) receive surgical treatment because of time-consuming preoperative staging and other interventions, including biliary drainage and portal vein embolization. Prolonged times potentially lead to unresectability and the formation of metastases, yet these issues have not been investigated previously in HCC. This study aimed to evaluate the time between onset of symptoms and the provision of ultimate treatment in patients with HCC and the impact of the length of time on outcomes.
  
  
  METHODS
  Delays in the treatment of consecutive patients with HCC were evaluated by contacting general practitioners (GPs) and extracting data from hospital files. Time periods were correlated with resectability, occurrence of metastasis, tumour stage and survival using logistic and Cox regression analyses.
  
  
  RESULTS
  Treatment times in 209 consecutive HCC patients were evaluated. The median time from first GP visit until presentation at the tertiary centre was 35 days. Time until treatment was longer when initial symptoms did not include jaundice (non-specific symptoms, P < 0.001). Duration of workup and preoperative biliary drainage at the tertiary centre prior to final surgical treatment resulted in an additional median time of 74 days. No correlation was found between treatment time in weeks and resectability [odds ratio (OR) 1.010, 95% confidence interval (CI) 0.985-1.036], metastasis (OR = 0.947, 95% CI 0.897-1.000), tumour stage (OR = 1.006, 95% CI 0.981-1.031) or survival in resected patients (hazard ratio = 0.996, 95% CI 0.975-1.018).
  
  
  CONCLUSIONS
  The time that elapses between the presentation of symptoms and final treatment in patients with HCC is substantial, especially in patients with non-specific symptoms. This time, however, does not affect resectability, metastasis, tumour stage or survival, which suggests that preoperative optimization should not be omitted because of potential delays in treatment.
authors.affiliation: Department of Surgery, Academic Medical Centre, Amsterdam, the Netherlands.
authors.forename: Anthony T
authors.initials: AT
authors.lastname: Ruys
authors.forename: Simon G
authors.initials: SG
authors.lastname: Heuts
authors.forename: Eric A
authors.initials: EA
authors.lastname: Rauws
authors.forename: Olivier R C
authors.initials: OR
authors.lastname: Busch
authors.forename: Dirk J
authors.initials: DJ
authors.lastname: Gouma
authors.forename: Thomas M
authors.initials: TM
authors.lastname: van Gulik
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 / Q000556:secondary / Q000601:surgery*; D004322:Drainage; D005260:Female; D006498:Hepatectomy / Q000009:adverse effects / Q000401:mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009367:Neoplasm Staging; D016017:Odds Ratio; D016016:Proportional Hazards Models; D012017:Referral and Consultation; D012307:Risk Factors; D062606:Tertiary Care Centers; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome
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