title: Bile duct surgery in the treatment of hepatobiliary and gallbladder malignancies: effects of hepatic and vascular resection on outcomes.
abstract: BACKGROUND
  Resection of the bile duct is required for the treatment of cholangiocarcinoma and is sometimes indicated in resections of liver and gallbladder malignancies. The goal of this retrospective review was to characterize surgical outcomes in patients submitted to bile duct resection for malignancy when additional procedures, specifically hepatic or vascular resections, were performed.
  
  
  METHODS
  The American College of Surgeons National Surgical Quality Improvement Program database was searched to identify a total of 747 patients who underwent: (i) biliary-enteric anastomosis (BEA) only (Group 1, n = 266); (ii) BEA with hepatic resection (Group 2, n = 439), or (iii) BEA with hepatic and vascular resection (Group 3, n = 42). Postoperative outcomes were compared and regression-adjusted risk factors were analysed to produce observed and expected (O/E) morbidity and mortality ratios.
  
  
  RESULTS
  The performance of hepatic and vascular resections significantly increased rates of overall morbidity (P < 0.001) and mortality (P = 0.021). Risk-adjusted O/E mortality ratios in Groups 1, 2 and 3 were 1.44 [95% confidence interval (CI) 0.84-2.30], 2.16 (95% CI 1.51-2.98) and 5.92 (95% CI 2.54-11.66), respectively. Multivariate analysis identified Group 2 (P < 0.001) and Group 3 (P = 0.001) status as independent predictors of morbidity, and Group 3 status (P = 0.008) as independently associated with mortality. More than 30% of deaths were associated with pulmonary complications and septic shock.
  
  
  CONCLUSIONS
  The addition of hepatic and vascular resections to bile duct resection significantly increased morbidity and mortality. The high O/E mortality ratios for patients in Groups 2 and 3 suggest these outcomes can be improved.
authors.affiliation: Surgical Surgical Oncology, Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
authors.forename: Perry
authors.identifier: http://orcid.org/0000-0002-7416-7829
authors.initials: P
authors.lastname: Shen
authors.affiliation: Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA.
authors.forename: Nora
authors.initials: N
authors.lastname: Fino
authors.affiliation: Surgical Surgical Oncology, Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
authors.forename: Edward A
authors.initials: EA
authors.lastname: Levine
authors.affiliation: Surgical Surgical Oncology, Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
authors.forename: Pamela
authors.initials: P
authors.lastname: Eversole
authors.affiliation: Surgical Surgical Oncology, Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
authors.forename: Clancy
authors.initials: C
authors.lastname: Clark
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical; D001650:Bile Duct Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D001652:Bile Ducts / Q000473:pathology / Q000601:surgery*; D001662:Biliary Tract Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D001808:Blood Vessels / Q000473:pathology; D016208:Databases, Factual; D005260:Female; D005706:Gallbladder Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D006498:Hepatectomy / Q000009:adverse effects / Q000401:mortality; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016015:Logistic Models; D008171:Lung Diseases / Q000209:etiology / Q000401:mortality; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012772:Shock, Septic / Q000209:etiology / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D055815:Young Adult