A methodological review of clinical outcomes reported in Liver Transplantation cholangiocarcinoma

Background: In patients undergoing resection for perihilar cholangiocarcinoma(PHC), intraoperative frozen sections are performed to assess completeness of the proximal and distal bile duct resection planes. In case of a positive proximal margin, re-resection of the bile duct stump is usually undertaken to achieve R0-resection. In case of a positive distal margin, additional PPPD (hepato-pancreatoduodenectomy, HPD) is considered. However, the Results of re-resection on R0-status and oncological outcomes in patients with PHC remain inconclusive. Therefore, we aimed to assess survival after re-resection of the bile duct after intra-operative positive frozen section in patients with PHC. Material and Methods: All consecutive patients undergoing resection for PHC at a single tertiary center between 2000-2018 were evaluated. Primary outcome was overall survival(OS), determined in patients with initial R0 resection, R1 resection and R0 resection after re-resection. Secondary outcome was severe morbidity(Clavien-Dindo=3). Results: A total of 162 PHC patients were evaluated(2000-2018), in which 30 positive intra-operative frozen sections were found in 27 patients. Additional resection was performed in 25 patients, representing 27 re-resections(Figure 1). In three cases re-resection was deemed technically not feasible. Re-resection at the distal resection margin(CBD) was performed in 8/27 patients, including 3 HPDs. Although Results of 18/27 re-resections(in 16 patients) were negative, 9 of the 16 patients (56%) still had R1 resection due to other positive, usually circumferential resection margins. Only four patients achieved true R0-resection after re-resection. Median OS for patients with initial R0, R1 and R0 after re-resection were 77, 35 and 33 months, respectively(p=0.334). Severe morbidity was not significantly different (72% after re-resection and 54% without re-resection, p=0.102). Conclusion: In the majority of patients (84%) undergoing re-resection of positive biliary margins in this series, R0-resection was not achieved, often due to additional positive resection margins.