The Impact of Intraoperative Re-Resection of a Positive Bile Duct Margin on Clinical Outcomes for Hilar Cholangiocarcinoma

Xu Feng Zhang, Malcolm H. Squires, Fabio Bagante, Cecilia G. Ethun, Ahmed Salem, Sharon M. Weber, Thuy Tran, George Poultsides, Andre Y. Son, Ioannis Hatzaras, Linda Jin, Ryan C. Fields, Matthew J Weiss, Charles Scoggins, Robert C.G. Martin, Chelsea A. Isom, Kamron Idrees, Harveshp D. Mogal, Perry Shen, Shishir K. MaithelCarl R. Schmidt, Timothy M. Pawlik

Research output: Contribution to journalArticle

Abstract

Background: The impact of re-resection of a positive intraoperative bile duct margin on clinical outcomes for resectable hilar cholangiocarcinoma (HCCA) remains controversial. We sought to define the impact of re-resection of an initially positive frozen-section bile duct margin on outcomes of patients undergoing surgery for HCCA. Methods: Patients who underwent curative-intent resection for HCCA between 2000 and 2014 were identified at 10 hepatobiliary centers. Short- and long-term outcomes were analyzed among patients stratified by margin status. Results: Among 215 (83.7%) patients who underwent frozen-section evaluation of the bile duct, 80 (37.2%) patients had a positive (R1) ductal margin, 58 (72.5%) underwent re-resection, and 29 ultimately had a secondary negative margin (secondary R0). There was no difference in morbidity, 30-day mortality, and length of stay among patients who had primary R0, secondary R0, and R1 resection (all p > 0.10). Median and 5-year survival were 22.3 months and 23.3%, respectively, among patients who had a primary R0 resection compared with 18.5 months and 7.9%, respectively, for patients with an R1 resection (p = 0.08). In contrast, among patients who had a secondary R0 margin with re-resection of the bile duct margin, median and 5-year survival were 30.6 months and 44.3%, respectively, which was comparable to patients with a primary R0 margin (p = 0.804). On multivariable analysis, R1 margin resection was associated with decreased survival (R1: hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.0–1.7; p = 0.027), but secondary R0 resection was associated with comparable long-term outcomes as primary R0 resection (HR 0.9, 95% CI 0.4–2.3; p = 0.829). Conclusions: Additional resection of a positive frozen-section ductal margin to achieve R0 resection was associated with improved long-term outcomes following curative-intent resection of HCCA.

Original languageEnglish (US)
Pages (from-to)1-10
Number of pages10
JournalAnnals of Surgical Oncology
DOIs
StateAccepted/In press - Feb 22 2018

ASJC Scopus subject areas

  • Surgery
  • Oncology

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    Zhang, X. F., Squires, M. H., Bagante, F., Ethun, C. G., Salem, A., Weber, S. M., Tran, T., Poultsides, G., Son, A. Y., Hatzaras, I., Jin, L., Fields, R. C., Weiss, M. J., Scoggins, C., Martin, R. C. G., Isom, C. A., Idrees, K., Mogal, H. D., Shen, P., ... Pawlik, T. M. (Accepted/In press). The Impact of Intraoperative Re-Resection of a Positive Bile Duct Margin on Clinical Outcomes for Hilar Cholangiocarcinoma. Annals of Surgical Oncology, 1-10. https://doi.org/10.1245/s10434-018-6382-0