title: Preoperative Cholangitis and Future Liver Remnant Volume Determine the Risk of Liver Failure in Patients Undergoing Resection for Hilar Cholangiocarcinoma.
abstract: The highest mortality rates after liver surgery are reported in patients who undergo resection for hilar cholangiocarcinoma (HCCA). In these patients, postoperative death usually follows the development of hepatic insufficiency. We sought to determine the factors associated with postoperative hepatic insufficiency and death due to liver failure in patients undergoing hepatectomy for HCCA.
  
  
  
  This study included all consecutive patients who underwent hepatectomy with curative intent for HCCA at 2 centers, from 1996 through 2013. Preoperative clinical and operative data were analyzed to identify independent determinants of hepatic insufficiency and liver failure-related death.
  
  
  
  The study included 133 patients with right or left major (n = 67) or extended (n = 66) hepatectomy. Preoperative biliary drainage was performed in 98 patients and was complicated by cholangitis in 40 cases. In all these patients, cholangitis was controlled before surgery. Major (Dindo III to IV) postoperative complications occurred in 73 patients (55%), with 29 suffering from hepatic insufficiency. Fifteen patients (11%) died within 90 days after surgery, 10 of them from liver failure. On multivariate analysis, predictors of postoperative hepatic insufficiency (all p < 0.05) were preoperative cholangitis (odds ratio [OR] 3.2), future liver remnant (FLR) volume < 30% (OR 3.5), preoperative total bilirubin level >3 mg/dL (OR 4), and albumin level < 3.5 mg/dL (OR 3.3). Only preoperative cholangitis (OR 7.5, p = 0.016) and FLR volume < 30% (OR 7.2, p = 0.019) predicted postoperative liver failure-related death.
  
  
  
  Preoperative cholangitis and insufficient FLR volume are major determinants of hepatic insufficiency and postoperative liver failure-related death. Given the association between biliary drainage and cholangitis, the preoperative approach to patients with HCCA should be optimized to minimize the risk of cholangitis.
authors.affiliation: Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey).
authors.forename: Dario
authors.initials: D
authors.lastname: Ribero
authors.affiliation: Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey).
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Zimmitti
authors.affiliation: Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey).
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Aloia
authors.affiliation: Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey).
authors.forename: Junichi
authors.initials: J
authors.lastname: Shindoh
authors.affiliation: Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey).
authors.forename: Forchino
authors.initials: F
authors.lastname: Fabio
authors.affiliation: Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey).
authors.forename: Marco
authors.initials: M
authors.lastname: Amisano
authors.affiliation: Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey).
authors.forename: Guillaume
authors.initials: G
authors.lastname: Passot
authors.affiliation: Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey).
authors.forename: Alessandro
authors.initials: A
authors.lastname: Ferrero
authors.affiliation: Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey).
authors.forename: Jean-Nicolas
authors.initials: JN
authors.lastname: Vauthey
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001650:Bile Duct Neoplasms / Q000150:complications / Q000601:surgery*; D002761:Cholangitis / Q000209:etiology*; D005260:Female; D006498:Hepatectomy; D006500:Hepatic Duct, Common / Q000601:surgery*; D006801:Humans; D018285:Klatskin Tumor / Q000150:complications / Q000601:surgery*; D008099:Liver / Q000033:anatomy & histology / Q000601:surgery; D017093:Liver Failure / Q000209:etiology* / Q000401:mortality; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009929:Organ Size; D011183:Postoperative Complications / Q000209:etiology* / Q000401:mortality; D057234:Preoperative Period; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome