Rare Surgical Procedure a Viable Option for Some Patients With Locally Advanced CCA

Hepatopancreatoduodenectomy (HPD) is rarely performed on patients with cholangiocarcinoma (CCA), in part because of its high rate of complications. However, a new case report published in the International Journal of Surgery Case Reports shows the procedure can be successful, even in patients initially deemed unresectable.

CCA is an aggressive form of cancer, and its location in the bile ducts can make it hard to diagnose in a timely fashion, and then hard to treat surgically. The first instance of HPD to treat longitudinally spreading CCA was reported in 1980. However, corresponding author Matteo Ravaioli, MD, PhD, of the University of Bologna, in Italy, and colleagues, noted that the procedure is uncommon. One key reason is that the postoperative morbidity rate is nearly 80% and the postoperative mortality rate is about 10%.

In their new report, Ravaioli and colleagues argue that the procedure should be seen as a potential option for patients whose cancers spread along the hepatic duct and choledocus, provided those patients are evaluated and treated at specialty centers with expert surgeons.

The new case report centers around a 73-year-old woman with locally advanced perihilar CCA. She had a good performance status and few other health problems, aside from mild hypertension.

After initial testing in a secondary hospital, the patient was deemed to have unresectable CCA. She was treated with a palliative bare self-expandable metal stent in her biliary tract. The patient experienced pancreatitis, but the complication was treated with medicine.

However, the patient wanted a second opinion. She went to Ravaioli’s hospital, where the tumor extension was reassessed and deemed stable, making the patient eligible for surgical exploration.

A volumetric examination suggested a future liver remnant (FLR) of at 31%.

“Therefore, considering the borderline volume of FLR and the possibility of cholestasis-induced liver toxicity, we decided to perform right portal vein embolization with the aim to reduce the risk of postoperative liver failure,” Ravaioli and colleagues said.

The procedure boosted the FLR by 7%.

A month later, the patient underwent HPD. She stayed in intensive care for 2 days, and then was discharged from the hospital after 16 days. Postoperatively, the patient experienced pancreatic biochemical leak and mild ascites, which were managed with medical therapy. There were no signs of liver failure. A wound infection also occurred, but it was managed with antibiotics and negative-pressure medication.

At the time of the report’s writing, it had been more than 6 months following the procedure and the patient remained alive without recurrence of the cancer.

Ravaioli and colleagues said the case highlights a number of important considerations when treating patients with perihilar cholangiocarcinoma. First, they noted that the initial determination that the cancer was unresectable led to a delay in therapy. They said it is critical to get the opinion of experts at referral centers when evaluating patients for surgery.

They also said the intrahepatic bile duct margin is a key consideration in whether or not to proceed with pancreatoduodenal resection.

“In fact, given the detrimental effect of R1 surgical margins on patient survival and the high rate of postoperative complications, HPD should be reserved for patients where the higher surgical risk can be counterbalanced with a better prognosis,” the investigators said.

Lastly, they said careful monitoring both before and after the procedure is essential, given the high rate of complications.

If the above conditions are met, Ravaioli and colleagues said HPD should be considered.

“Despite the magnitude of the intervention and the high risk of postoperative complications, patients can be managed in high-skill and volume hepatobiliary centers where risk mitigation strategies can be adopted, and complications can be handled without risk of failure-to-rescue,” they concluded.

Reference

Fallani G, Cappelli A, Siniscalchi A, Vasuri F, Germinario G, Ravaioli M. Hepatopancreatoduodenectomy for locally advanced perihilar cholangiocarcinoma: a case report and a plea not to underestimate surgical resectability. Int J Surg Case Rep. Published online August 9, 2022. doi:10.1016/j.ijscr.2022.107495