Role Of Preoperative Portal Vein Embolization In The Treatment Of Type Ⅲ Or Ⅳ Hilar Cholangiocarcmoma

Backgroud&ObjectivesAt present,the morbidity of hilar cholangiocarcinoma has been ranked in secondplace in biliary epithelial malignant tumors,with showing a trend of rising year byyear.As is well-known,curative resection has been reported to be only hope of cure forthe patients with hilar cholangiocarcinoma.But for patients with Bismuth-Corlett IVtype or III type hilar cholangiocarcinoma,the en bloc liver resection is recommendedand caudate resection is strongly encouraged.It’s an invasive surgery with seriousrisks and higher rate of complications.So,radical surgery for hilar cholangiocarcinomahave long been a challenge in the field of abdominal surgery.In recentyears,preoperative portal vein embolization is ofen performed as a routine procedurebefore extended hepatectomy especially for patients with Bismuth-Corlette IV type orIII type hilar cholangiocarcinoma.This technology not only affect the hypertrophy ofthe future liver remnant(FLR),but also atrophy the liver volume to be resected.So, thesafety of major hepatectomy is improved,postoperative liver failure is minimized.To explore the preoperative portal vein embolization and its influence on theprognosis.The results of this study will provide some experience and enlightenmentfor clinical treatment of hilar cholangiocarcinoma.MethodsFrom January2007to December2011,the data of109patients withBismuth-Corlette IV type or III type hilar cholangiocarcinoma,who undergohemi-hepatectomy/extended hepatectomy plus caudate lobe resection wereretrospectively analyzed.Patients were divided according to if they had previousPVE.Preoperative PVE was performed in36patients(PVE group) and was not appliedin73patients(non-PVE group).The therapeutic effect of two group cases wereobserved and compared.In order to find the independent factors for postoperative R0resection.,variablesthat associated with postoperative R0resection were included in the multivariateanalysis using Logisics regression.In order to identify the independent factors forsurvival,variables that associated with survival in univariate analysis weresubsequently included in the multivariate analysis using Cox proportional harzardmodel.ResultsPVE for all36cases of the PVE group was effective, reservation liver volumerate significantly increased (41.464±2.340%vs45.853±3.922%), and no PVE-related complications occurred. All73cases of the control groups received successful radicalresection. R0resection rate was97.22%for PVE group and78.08%for control group,chi-square test showed significant difference between the two (P=0.010).Postoperative complications were30.56%and30.14%for PVE group and controlgroup, and chi-square test showed no significant difference between the two (P=0.964). No postoperative liver failure occurred in PVE group while it occurred in twocases from control group, one of which died in spite of active treatment. There were2postoperative in-hospital deaths in PVE group and3in control group. Postoperativesurvival was18.782months for the PVE group and16.343for the control group onaverage.The median survival time is18.782months in PVE group,and is16.148months in non-PVE group.The difference between two groups was of no statisticalsignificance(P>0.05).The survival rate at6,12,18and24months after treatment was83.3%,66.7%,47.2%and30.1%,respectively in PVE group,was76.7%,50.2%,33.5%and16%respectively in non-PVE group.PVE before surgery positively correlates with the rate of R0resection（OR,10.297;95%CI,1.275-83.189,P=0.029）which is negatively correlated withregional lymph node metastasis(OR,0.075;95%CI,0.009-0.598,P=0.015). Multivariateanalysis showed that PVE was not a significant prognostic factor（influencingpostoperative survival.）,but surgical procedure of R0standard （HR,0.499;95%CI,0.291-0.856,P=0.012）is an independent predictors of the postoperativeprognosis for patient undergoing surgical treatment.(affected postoperative survivalsignificantly)ConclusionPreoperative portal vein embolization (PVE) is a much safe and reliable surgicaltechnique that can significantly improve the rate of R0resection and resectability intype III and IV hilar cholangiocarcinoma cases, expanding the indications for surgery,which makes combined and expanded liver resection possible for more patients, butthere was no definitive extension in long-term survival of the patients. Patientsreceived R0resection would achieve more favorable prognosis.