title: When hepatic-side ductal margin is positive in N+ cases, additional resection of the bile duct is not necessary to render the negative hepatic-side ductal margin during surgery for extrahepatic distal bile duct carcinoma.
abstract: BACKGROUND
  The current standard treatment for extrahepatic distal bile duct carcinoma (EDBDC) is surgical resection, as no effective alternative treatment exists. In this study, we investigated the treatment strategies and outcomes for 90 cases of EDBDC at our department.
  
  
  METHODS
  Between April 2000 and March 2013, 90 pancreatoduodenectomies (PDs) were performed for EDBDC. The mean patient age was 69.1 ± 9.8 years, and there were 59 males and 31 females. Extended lymph adenectomy including lymph nodes around the common hepatic artery and celiac axis was performed in all patients. The mean operation time was 537.1 ± 153.8 min and the mean operative blood loss was 814.0 ± 494.0 ml. There were no operation-related deaths. The overall 1-, 3-, and 5-year survival rates were 90.0%, 51.2%, and 45.0%, respectively.
  
  
  RESULTS
  Lymph node metastasis was present in 28 patients (N+; 31.1%), and it was absent in 62 (N-; 68.9%). The 5-year survival rate was 20.0% for N+ patients and 52.4% for N- patients, which is significantly higher (P=0.03). Nine cases (10.0%) showed hepatic-side ductal margin (HM) positivity for carcinoma. The 5-year survival rate was 18.7% for HM-positive patients and 48.3% for HM-negative patients, which is significantly higher (P=0.005). In multivariate analysis, N+ was the strongest adverse prognostic factor. Subclass analysis of 62 cases (excluding 28 N+ cases) revealed 7 patients with positive HMs (11.3%) and 55 patients with negative HMs (88.7%). The 5-year survival rate was 47.6% for HM-positive patients and 49.8% for HM-negative patients (P=0.73). Thirty-five cases (38.9%) recurred: there were 19 cases of local recurrence (21.1%), 11 cases of liver metastasis (12.2%), 4 cases of distant recurrence (4.4%), and 1 case of para-aortic lymph node metastasis (1.1%).
  
  
  CONCLUSIONS
  In conclusion, when HM is positive in N+ cases, additional resection of the bile duct is not necessary to render the HM negative for carcinoma.
authors.affiliation: Department of Gastroenterological Surgery, Dokkyo Medical University, Tochigi, Japan.
authors.forename: Yukihiro
authors.initials: Y
authors.lastname: Iso
authors.affiliation: Department of Gastroenterological Surgery, Dokkyo Medical University, Tochigi, Japan.
authors.forename: Junji
authors.initials: J
authors.lastname: Kita
authors.affiliation: Department of Gastroenterological Surgery, Dokkyo Medical University, Tochigi, Japan.
authors.forename: Masato
authors.initials: M
authors.lastname: Kato
authors.affiliation: Department of Gastroenterological Surgery, Dokkyo Medical University, Tochigi, Japan.
authors.forename: Mitsugi
authors.initials: M
authors.lastname: Shimoda
authors.affiliation: Department of Gastroenterological Surgery, Dokkyo Medical University, Tochigi, Japan.
authors.forename: Keiiehi
authors.initials: K
authors.lastname: Kubota
mesh_terms: D000368:Aged; D001650:Bile Duct Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D017734:Bile Ducts, Extrahepatic / Q000473:pathology* / Q000601:surgery*; D005260:Female; D006801:Humans; D016015:Logistic Models; D008207:Lymphatic Metastasis / Q000473:pathology*; D008297:Male; D015999:Multivariate Analysis; D009367:Neoplasm Staging; D015996:Survival Rate