title: Pancreaticoduodenectomy for distal cholangiocarcinoma: surgical results, prognostic factors, and long-term follow-up.
abstract: OBJECTIVE
  Prognostic indicators for distal cholangiocarcinoma have not been widely confirmed because of its rarity. Despite the early appearance of symptoms, it has a very poor prognosis. The aim of this study was to identify prognostic factors in patients undergoing pancreaticoduodenectomy (PD) for distal bile duct cancer (DBDC) in a high-volume center for pancreatic disease.
  
  
  METHODS
  From January 2000 to December 2013, 1490 PD were performed for periampullary disease. Data from all patients with histologically proven cholangiocarcinoma were reviewed. Preoperative data, post-operative complications, pathologic features, and survival were investigated.
  
  
  RESULTS
  Among 50 histologically proven DBDC (3.3 %), 4 patients who underwent CBD resection were excluded. Thus, the study population consisted of 46 patients. Overall surgical morbidity rate was 67.4 %; mortality was nil. Major complications were pancreatic fistula (47.8 %), abdominal collections (34.8 %), post-pancreatectomy hemorrhage (21.7 %), and delayed gastric emptying (10.9 %). The majority of resections were R0 (73.9 %). The presence of metastatic lymph nodes (N1) was identified in 76.1 % of cases. Among N1 cases, the most frequently involved lymph nodes were pancreaticoduodenal nodes (50 %), hepatoduodenal ligament nodes (21.7 %), superior mesenteric artery nodes (8.7 %), and anterior hepatic artery nodes (4.3 %). Overall, survival rates were 88.8, 40, and 18 % at 1, 3, and 5 years, respectively. Median survival was 31 months. By univariate analysis, only tumor grading and nodal metastasis were predictors of poor prognosis (p < 0.05). These findings were not confirmed in multivariate analysis.
  
  
  CONCLUSIONS
  This study shows that DBDC is a rare entity even if large surgical series are reviewed. Tumor differentiation and nodal status have been confirmed as important prognostic factors. Pancreaticoduodenectomy remains the procedure of choice in order to obtain free surgical margins and in order to harvest the correct number of lymph nodes for a correct staging.
authors.affiliation: Unit of General and Pancreatic Surgery, The Pancreas Institute, Department of Surgery and Oncology; G.B. Rossi Hospital, University of Verona Hospital Trust, P.Le L.A. Scuro 10, 37134, Verona, Italy, stefano.andrianello@gmail.com.
authors.forename: Stefano
authors.initials: S
authors.lastname: Andrianello
authors.forename: Salvatore
authors.initials: S
authors.lastname: Paiella
authors.forename: Valentina
authors.initials: V
authors.lastname: Allegrini
authors.forename: Marco
authors.initials: M
authors.lastname: Ramera
authors.forename: Alessandra
authors.initials: A
authors.lastname: Pulvirenti
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Malleo
authors.forename: Roberto
authors.initials: R
authors.lastname: Salvia
authors.forename: Claudio
authors.initials: C
authors.lastname: Bassi
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001650:Bile Duct Neoplasms / Q000601:surgery*; D018281:Cholangiocarcinoma / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D016577:Pancreaticoduodenectomy; D011183:Postoperative Complications; D011379:Prognosis; D015996:Survival Rate; D016896:Treatment Outcome