Operative and Oncological Outcomes of Vascular Resection and Reconstruction for Perihilar Cholangiocarcinoma

Background. Hepatectomy with associated vascular resection and reconstruction (VR) is an option to increase the number of patients with locally advanced perihilar cholangiocarcinoma (pCCA) eligible for radical-intent surgery. Objectives. This study aimed to assess the safety and oncological outcomes of VR in pCCA patients. Methods. Patients who underwent surgery for pCCA at 10 western centers were retrospectively reviewed and divided according to the performance of the VR. Primary outcomes were major morbidity, vascular morbidity, 90-day mortality, and overall survival (OS). Results. A total of 1054 patients were included, of whom 259 (24.6%) underwent VR. Of these 259 patients, 199 (76.8 %) underwent portal vein reconstruction (PVR) only and 60 (23.2%) underwent hepatic artery reconstruction (HAR) with or without PVR. VR patients were younger (66 vs. 68 years; p = 0.011) and more frequently had Bismuth type 4 tumors (31.3% vs. 22.9%; p = 0.008). They more frequently underwent portal vein embolization (32.0% vs. 17.6%; p < 0.001), biliary drainage (84.9% vs. 77.3%; p = 0.008), and extended hepatectomy (56.8% vs. 37.1%; p < 0.001), with longer operative times (539 vs. 479 min; p < 0.001) and higher blood loss (1300 vs. 700 mL; p < 0.001). Positive resection margins were observed more frequently (45.7% vs. 35.2%; p = 0.003). Major complications (51.4% vs. 41.0%; p = 0.004), vascular complications (19.7% vs. 3.3%; p < 0.001), and mortality (16.2% vs. 10.6%; p = 0.02) were higher in VR patients. Median OS was 28.0 months for patients without VR versus 22.8 months for patients with VR (p = 0.18). Conclusions. Liver resection and VR in patients with locally advanced pCCA are associated with increased major and vascular morbidity but offer similar survival as patients not undergoing VR; therefore, VR should be considered in selected patients.