Past

Pancreaticoduodenectomy (PD) is a standardized resection for distal cholangiocarcinoma. If the tumor is located in the middle-third bile duct alone, bile duct resection (BDR) may be considered as an alternative approach. However, this tumor is rare, with an incidence of about 13% among all cholangiocarcinomas,1 and recent surveys have observed that BDR accounted for only 1.5–2.7% of resections for cholangiocarcinoma.2,3 Therefore, the oncologic benefit of BDR remains poorly understood.

Present

The authors conducted a multi-institutional retrospective study of 92 patients who underwent BDR (n = 38) or PD (n = 54) for middle-third cholangiocarcinoma.4 The short-term outcomes involving operation time, blood loss, complications, and mortality were better with BDR than with PD. The survival rate after BDR was significantly worse than after PD (38.8% vs 54.8% at 5 years; P = 0.035), and BDR was an independent factor deteriorating survival. Subgroup analysis in the BDR group, however, demonstrated that tumor < 15 mm and margin ≥ 10 mm lead to better survival, similar to the PD group.

Future

The data from this study demonstrated that middle-third cholangiocarcinoma remains a dreaded disease potentially affected by surgical procedure. Although BDR may be easy to use and patient friendly, it should be performed for strictly selected patients based on tumor length and expected ductal margin rather than patient risk. Thus, from the viewpoint of surgical oncology, a very small population of patients with cholangiocarcinoma seems to benefit from BDR. In reality, a prospective randomized study is impractical due to the rarity and inferiority of the tumor. Well-designed retrospective studies are needed for further integration of analysis.