SURGICAL-TREATMENT OF CARCINOMA OF THE HEPATIC DUCT CONFLUENCE - ANALYSIS OF 55 RESECTED CARCINOMAS

We treated 65 patients with carcinoma of the hepatic duct confluence between 1976 and 1991, 57 (87.7%) of whom were treated surgically; of the 57, 55 (96.5%) underwent resection. Radical resection was performed at a rate of 50.9%. Procedures for these 55 patients included resection or the extrahepatic bile duct plus hepatectomy (n = 33; 60.0%), and resection of the duct without hepatectomy (n = 22; 40.0%). In addition, the caudate lobe was resected in 28 of these patients, and the portal vein, hepatic artery, or both were resected in 6. The overall operative morbidity was 21.8%; morbidity occurred in 33.3% of patients with hepatectomy, a significantly higher percent than the 4.5% rate in those without hepatectomy (p < 0.05). Operative death occurred in only 1.9%. As the depth of cancer invasion in the bile duct wall advanced, the incidence of tumor spread (e.g., lymphatic permeation, venous invasion, perineural invasion, lymph node metastasis) increased significantly. The prevalence of extramural tumor extensions in a transverse direction was higher than that in the longitudinal direction along the bile duct wall; and the distance from the margin of the primary tumor to the site of tumor extensions along the bile duct wall was much longer on the hepatic side than on the duodenal side. Cancer invasion of the caudate lobe was observed in 36.4%, and invasion at the surgical margins was found more frequently in those without hepatectomy than those with hepatectomy. Cumulative 1-, 3-, and 5-year survival rates in patients with hepatectomy were 83.5%, 37.1%, and 23.2%, respectively-significantly higher than the 44.3%, 18.5%, and 18.5% rates in patients without hepatectomy (p < 0.05). Furthermore, cumulative survival rates were higher for hepatectomy patients with resection of the caudate lobe than for those without resection of the caudate lobe. The results indicate that hepatectomy improves prognosis because cancer frequently invades the surgical margins in these tumors, although postoperative morbidity is higher with this procedure. Hence for poor-risk patients (e.g., the elderly, those with poor hepatic functional reserve), caudate lobectomy with or without hilar hepatectomy may be the procedure or choice.