Reappraisal of the Clinical Utility of Hi-Cut Pancreaticoduodenectomy for Widespread Distal Cholangiocarcinoma: A Less Invasive Alternative to Hepatopancreatoduodenectomy.

Abstract

The efficacy of Hi-cut pancreaticoduodenectomy (PD) for widespread distal cholangiocarcinoma (DCC) remains unclear. This study re-evaluated the impact of Hi-cut PD on survival, recurrence, and short-term complications. The study retrospectively enrolled patients who underwent curative-intent PD for DCC between 2005 and 2021. Hi-cut PD was defined as bile duct resection beyond the midpoint between the superior border of the pancreas and the hepatic duct confluence. Bile duct margin status was classified as group A (negative or carcinoma in situ by PD), group B (negative or carcinoma in situ by Hi-cut PD), or group C (residual invasive cancer by Hi-cut PD). The study enrolled 104 patients: 52 (50.0%) in group A, 46 (44.2%) in group B, and 6 (5.8%) in group C. The 5-year overall survival rates in groups A and B were comparable (52.3% vs 52.5%; p = 0.793). The patients without lymph node metastasis had a significantly better 5-year overall survival in group B than in group C (70% vs 25%; p = 0.027). Local recurrence rates were similar between the groups, and major surgical complications (Clavien-Dindo ≥IIIa) were comparable between groups A and B (15.4% vs 21.7%; p = 0.418). Although multiple bile duct orifices were most frequent in group B, the incidence of biliary fistula increased significantly only when five or more orifices were reconstructed (40% vs 4% with one orifice; p = 0.003). Hi-cut PD for widespread DCC yielded survival outcomes comparable with PD without increasing local recurrence or major short-term complication rates, supporting its feasibility and oncologic validity as a less invasive alternative to hepatopancreatoduodenectomy for select patients.