Prevention and treatment of severe complications after radical surgery for portal cholangiocarcinoma

   Aim. To develop the concept of prevention and treatment of severe complications after radical surgery for portal cholangiocarcinoma based on a comparative analysis of two periods of the surgical treatment program.

   Materials and methods. The study involved an analysis of multidisciplinary treatment of patients with portal cholangiocarcinoma for 8 years (2013–2020). The study consisted of two stages: program formation in 2013–2018 and evaluation of results in 2019–2020.

   Results. 140 patients with portal cholangiocarcinoma underwent radical or relatively radical surgery: 94 patients in the first period and 46 patients in the second period. 35 pairs of observations were formed by means of propensity score matching. In the second period, the incidence of Clavien-Dindo grade IV and V complications, CCI>40 index, duration of stay in the intensive care unit, and 90-day mortality significantly decreased. Proven reasons for the improvements included more thorough preparation of patients for the resection stage of treatment, elimination of clinical and laboratory manifestations of biliary drainage complications, careful invasive monitoring of fluid accumulations, and prevention of cholangitis.

   Conclusion. Maximum compensation of inflammatory and trophic disorders, elimination of jaundice, prevention and early elimination of complications as a result of their prognosis and monitoring at all stages of treatment reliably improve the immediate results of radical surgery for portal cholangiocarcinoma.

1. Vishnevskij V.A., Tarasyuk T.I. Diagnosis and surgical treatment of proximal hepatic ductal cancer (Klatskin tumors). Practical Oncology. 2004; 5 (2): 126–134. (In Russian)

2. Jarnagin W.R., Fong Y., DeMatteo R.P., Gonen M., Burke E.C., Bodniewicz J., Youssef M., Klimstra D., Blumgart L.H. Staging, resectability, and outcome in 225 patients with hilar cholangiocarcinoma. Ann. Surg. 2001; 234 (4): 507–519. doi: 10.1097/00000658-200110000-00010

3. Coelen R.J., Olthof P.B., van Dieren S., Besselink M.G., Busch O.R., van Gulik T.M. External validation of the estimation of physiologic ability and surgical stress (E-PASS) risk model to predict operative risk in perihilar cholangiocarcinoma. JAMA Surg. 2016; 147: 26–34. doi: 10.1001/jamasurg.2016.2305

4. Ito F., Cho C.S., Rikkers L.F., Weber S.M. Hilar cholangiocarcinoma: current management. Ann. Surg. 2009; 250 (2): 210–218. doi: 10.1097/SLA.0b013e3181afe0ab

5. Chan F.L. Evaluation of recurrent pyogenic cholangitis with CT: analysis of 50 patients. Radiology. 1989; 170 (1 Pt 1): 165–169. doi: 10.1148/radiology.170.1.2909092

6. Chu K.M., Fan S.T., Lai E.C., Lo C.M., Wong J. Pyogenic liver abscess. An audit of experience over the past decade. Arch. Surg. 1996; 131 (2): 148–152. doi: 10.1001/archsurg.1996.01430140038009

7. Law S.T., Li K.K. Is pyogenic liver abscess associated with recurrent pyogenic cholangitis a distinct clinical entity? A retrospective analysis over a 10-year period in a regional hospital. Eur. J. Gastroenterol. Hepatol. 2011; 23 (9): 770–777. doi: 10.1097/MEG.0b013e328348cb9c

8. Okuno W.T., Whitman G.J., Chew F.S. Recurrent pyogenic cholangiohepatitis. Am. J. Roentgenol. 1996; 167 (2): 484. doi: 10.2214/ajr.167.2.8686632

9. Tian L.T., Yao K., Zhang X.Y., Zhang Z.D., Liang Y.J., Yin D.L., Lee L., Jiang H.C., Liu L.X. Liver abscesses in adult patients with and without diabetes mellitus: an analysis of the clinical characteristics, features of the causative pathogens, outcomes and predictors of fatality: a report based on a large population, retrospective study in China. Clin. Microbiol. Infect. 2012; 18 (9): E314–E330. doi: 10.1111/j.1469-0691.2012.03912.x

10. Tsai F.C., Huang Y.T., Chang L.Y., Wang J.T. Pyogenic liver abscess as endemic disease, Taiwan. Emerg. Infect. Dis. 2008; 14 (10): 1592–1600. doi: 10.3201/eid1410.071254

11. Van der Gaag N.A., Rauws E.A., van Eijck C.H. Preoperative biliary drainage for cancer of the head of the pancreas. N. Engl. J. Med. 2010; 362 (2): 129–137. doi: 10.1056/NEJMoa0903230

12. Nakanishi Y., Tsuchikawa T., Okamura K., Nakamura T., Tamoto E., Noji T., Asano T., Amano T., Shichinohe T., Hirano S. Risk factors for a high Comprehensive Complication Index score after major hepatectomy for biliary cancer: a study of 229 patients at a single institution. HPB (Oxford). 2016; 18 (9): 735–741. doi: 10.1016/j.hpb.2016.06.013

13. Olthof P.B., Wiggers J.K., Groot Koerkamp B., Coelen R.J., Allen P.J., Besselink M.G., Busch O.R., D'Angelica M.I., DeMatteo R.P., Kingham T.P., van Lienden K.P., Jarnagin W.R., van Gulik T.M. Postoperative Liver Failure Risk Score: identifying patients with resectable perihilar cholangiocarcinoma who can benefit from portal vein embolization. J. Am. Coll. Surg. 2017; 225 (3): 387–394. doi: 10.1016/j.jamcollsurg.2017.06.007

14. Vishnevskij V.A., Efanov M.G., Ikramov R.Z., Nazarenko N.A., Shevchenko T.V., Ionkin D.A., Chzhao A.V. Long-term results after R0 and R11 resections in patients with hilar cholangiocarcinoma. Annaly khirurgicheskoy gepatologii = Annals of HPB Surgery. 2013; 18 (2): 9–20. (In Russian)

15. Ruzzenente A., Alaimo L., Caputo M., Conci S., Campagnaro T., De Bellis M., Bagante F., Pedrazzani C., Guglielmi A. Infectious complications after surgery for perihilar cholangiocarcinoma: a single Western center experience. Surgery. 2022; 172 (3): 813–820. doi: 10.1016/j.surg.2022.04.028

16. Wang Y., Fu W., Tang Z., Meng W., Zhou W., Li X. Effect of preoperative cholangitis on prognosis of patients with hilar cholangiocarcinoma : a systematic review and meta-analysis. Medicine (Baltimore). 2018; 97 (34): e120–125. doi: 10.1097/MD.0000000000012025

17. Nagino M., Ebata T., Mizuno T. Oncological superiority of right-sided hepatectomy over left-sided hepatectomy as surgery for perihilar cholangiocarcinoma: truth or biased view? Ann. Surg. 2021; 274 (1): 31–32. doi: 10.1097/SLA.0000000000004534

18. Brooke-Smith M., Figueras J., Ullah S., Rees M., Vauthey J.-N., Hugh T.J. Prospective evaluation of the International Study Group for Liver Surgery definition of bile leak after a liver resection and the role of routine operative drainage: an international multicentre study. HPB. 2015; 17 (1): 46–51. doi: 10.1111/hpb.12322

19. Efanov M., Alikhanov R., Zamanov E., Melekhina O., Kulezneva Y., Kazakov I., Vankovich A., Koroleva A., Tsvirkun V. Combining E-PASS model and disease specific risk factors to predict severe morbidity after liver and bile duct resection for perihilar cholangiocarcinoma. HPB (Oxford). 2021; 23 (3): 387–393. doi: 10.1016/j.hpb.2020.07.009

20. Haga Y., Miyamoto A., Wada Y., Takami Y., Takeuchi H. Value of E-PASS models for predicting postoperative morbidity and mortality in resection of perihilar cholangiocarcinoma and gallbladder carcinoma. HPB. 2016; 18 (3): 271–278. doi: 10.1016/j.hpb.2015.09.001