Hepatopancreatoduodenectomy for extrahepatic cholangiocarcinoma: a series of 100 consecutive cases from an expert center in Japan

Introduction: Hepatopancreatoduodenectomy (HPD) is used for laterally spreading cholangiocarcinomas. However, the procedure remains controversial due to high morbidity, mortality and uncertain oncological benefits. Methods: A total of 100 patients undergoing HPD between 2003 and 2020 were reviewed. Short- and long-term outcomes were compared with those of hepatectomy with extrahepatic bile duct resection (HT-B) (n=203) and pancreatoduodenectomy (PD) (n=209). Results: Operating time and blood loss of HPD were 668 min and 1842 ml, which were significantly longer and greater in comparison to the HT-B (552 min and 1264 ml) and PD (457 min and 911 ml) groups. Clinically relevant postoperative complications (Clavien-Dindo grade >3) after HPD was 82%, which was significantly greater in comparison to the HT-B (39%) and PD (68%) groups. However, the mortality rate was 2% and was almost comparable to the HT-B (2.5%) and PD (1.4%) groups. The 3- and, 5-year survival rate, and median survival time were 59.0%, 40.7%, and 50 months, respectively, in the HPD group; 61.1%, 41.8%, and 45 months in the HT-B group; and 60.7%, 45.4%, and 48 months in the PD group. No significant differences were observed between the groups. Thirty-six patients survived for more than 5-years. Multivariate analysis revealed that CA 19-9 >100 U/ml, pT3/T4, combined vascular resection, and lymph node metastasis were significant prognostic factors in HPD. Conclusion: Although HPD is technically demanding and forces stress on patients, it can be performed with acceptable mortality and survival. HPD for widely spreading cholangiocarcinoma should be considered standard procedure in expert hepato-pancreato-biliary centers.