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Converted-hepatopancreatoduodenectomy for an intraoperative positive ductal margin after pancreatoduodenectomy in distal cholangiocarcinoma

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Abstract

Purpose

Pancreatoduodenectomy (PD) is the standard treatment for distal cholangiocarcinoma, and a negative ductal margin (DM0) is indispensable for the long-term survival. When intraoperative frozen sections of ductal margin after PD are positive, converted-hepatopancreatoduodenectomy (C-HPD) is the final option available to gain an additional ductal margin. However, the efficacy of C-HPD remains unclear.

Methods

Patients who underwent PD or C-HPD for distal cholangiocarcinoma between 2002 and 2019 were analyzed. The type of hepatectomy in C-HPD was restricted to left hepatectomy to prevent posthepatectomy liver failure.

Results

Of 203 patients who underwent PD for distal cholangiocarcinoma, 49 patients exhibited intraoperative positive ductal margin (DM1) after PD. Eleven patients underwent C-HPD for intraoperative DM1 after PD, in which intraoperative DM1 with invasive carcinoma (DM1inv) was observed in 3 patients, and intraoperative DM1 with carcinoma in situ (DM1cis) was observed in 8 patients. The median additional ductal margin yielded by C-HPD was 9 mm (interquartile range 7–13 mm). C-HPD eradicated intraoperative DM1inv in 3 patients, with 2 patients showing DM0 and 1 patient showing DM1cis. Regarding 8 patients who underwent C-HPD for intraoperative DM1cis, 4 patients had DM0, but the others had DM1cis. C-HPD was associated with a high complication rate, but no mortality was observed. The median survival time of patients who underwent C-HPD was 48.8 months.

Conclusion

C-HPD was able to safely eradicate intraoperative DM1inv after PD. However, the length of the resected bile duct according to C-HPD may not be sufficient to remove intraoperative DM1cis after PD.

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Authors and Affiliations

  1. Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007 Shimo-Nagakubo, Sunto-Nagaizumi, Shizuoka, 411-8777, Japan

    Ryusei Yamamoto, Teiichi Sugiura, Ryo Ashida, Katsuhisa Ohgi, Mihoko Yamada, Shimpei Otsuka, Yukiyasu Okamura & Katsuhiko Uesaka

Authors
  1. Ryusei Yamamoto
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  2. Teiichi Sugiura
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  3. Ryo Ashida
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  4. Katsuhisa Ohgi
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  5. Mihoko Yamada
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  6. Shimpei Otsuka
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  7. Yukiyasu Okamura
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  8. Katsuhiko Uesaka
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Contributions

Study conception and design: RY, ST, and UK. Acquisition of data: RY and ST. Analysis and interpretation of data: RY and ST. Drafting of manuscript: RY and ST. Critical revision of manuscript: all authors.

Corresponding author

Correspondence to Teiichi Sugiura.

Ethics declarations

Ethics approval

The protocol for this research project was approved by a suitably institutional ethics committee and conformed to the provisions of the Declaration of Helsinki. The Institutional Review Board of Shizuoka Cancer Center approved the study (Approval No. J2019-71–2019-1–2).

Consent to participate

Informed consent was substituted by the informed opt-out procedure because of the retrospective nature of the study, and anonymous clinical data were used for the analysis.

Conflict of interest

The authors declare no competing interests.

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Supplemental Fig. 1

Intraoperative picture of converted-hepatopancreatoduodenectomy (C-HPD) just before resection of the right hepatic duct (broken line). The arrow indicates the stump of the right hepatic duct after pancreatoduodenectomy. *The additional ductal margin yielded by C-HPD. LHD, left hepatic duct; MHV, middle hepatic vein; RPV, right portal vein; RHA, right hepatic artery. (PNG 7595 kb)

High Resolution (TIFF 4238 kb)

Supplemental Fig. 2

The overall survival according to the ductal margin in patients who underwent converted-hepatopancreatoduodenectomy. DM0, negative ductal margin; DM1cis, positive ductal margin with carcinoma in situ. (PNG 185 kb)

High Resolution (TIFF 1898 kb)

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Yamamoto, R., Sugiura, T., Ashida, R. et al. Converted-hepatopancreatoduodenectomy for an intraoperative positive ductal margin after pancreatoduodenectomy in distal cholangiocarcinoma. Langenbecks Arch Surg 407, 2843–2852 (2022). https://doi.org/10.1007/s00423-022-02598-2

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  • DOI: https://doi.org/10.1007/s00423-022-02598-2

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