• Dario Ribero, Giuseppe Zimmitti, Thomas A Aloia, Junichi Shindoh, Forchino Fabio, Marco Amisano, Guillaume Passot, Alessandro Ferrero, and Jean-Nicolas Vauthey.
• Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey).
• J. Am. Coll. Surg. 2016 Jul 1; 223 (1): 879787-97.

BackgroundThe highest mortality rates after liver surgery are reported in patients who undergo resection for hilar cholangiocarcinoma (HCCA). In these patients, postoperative death usually follows the development of hepatic insufficiency. We sought to determine the factors associated with postoperative hepatic insufficiency and death due to liver failure in patients undergoing hepatectomy for HCCA.Study DesignThis study included all consecutive patients who underwent hepatectomy with curative intent for HCCA at 2 centers, from 1996 through 2013. Preoperative clinical and operative data were analyzed to identify independent determinants of hepatic insufficiency and liver failure-related death.ResultsThe study included 133 patients with right or left major (n = 67) or extended (n = 66) hepatectomy. Preoperative biliary drainage was performed in 98 patients and was complicated by cholangitis in 40 cases. In all these patients, cholangitis was controlled before surgery. Major (Dindo III to IV) postoperative complications occurred in 73 patients (55%), with 29 suffering from hepatic insufficiency. Fifteen patients (11%) died within 90 days after surgery, 10 of them from liver failure. On multivariate analysis, predictors of postoperative hepatic insufficiency (all p < 0.05) were preoperative cholangitis (odds ratio [OR] 3.2), future liver remnant (FLR) volume < 30% (OR 3.5), preoperative total bilirubin level >3 mg/dL (OR 4), and albumin level < 3.5 mg/dL (OR 3.3). Only preoperative cholangitis (OR 7.5, p = 0.016) and FLR volume < 30% (OR 7.2, p = 0.019) predicted postoperative liver failure-related death.ConclusionsPreoperative cholangitis and insufficient FLR volume are major determinants of hepatic insufficiency and postoperative liver failure-related death. Given the association between biliary drainage and cholangitis, the preoperative approach to patients with HCCA should be optimized to minimize the risk of cholangitis.Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

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