Univariate and Multivariate Analysis of Prognostic Factors in the Surgical Treatment of Hilar Cholangiocarcinoma GIOVANNI RAMACCIATO, M.D.,* GIUSEPPE NIGRI, M.D., PH.D.,* RICCARDO BELLAGAMBA, M.D.,* NICCOLO ` PETRUCCIANI, M.D.,* MATTEO RAVAIOLI, M.D.,†MATTEO CESCON, M.D.,† MASSIMO DEL GAUDIO, M.D.,† GIORGIO ERCOLANI, M.D.,† FABRIZIO DI BENEDETTO, M.D.,† NICOLA CAUTERO, M.D.,† CRISTIANO QUINTINI, M.D.,‡ ALESSANDRO CUCCHETTI, M.D.,† AUGUSTO LAURO, M.D.,† CHARLES MILLER, M.D.,‡ ANTONIO DANIELE PINNA, M.D.† From the *Department of General Surgery, Hepato-biliary-pancreatic Unit, University of Rome ‘‘La Sapienza,’’ II° School of Medicine, Sant’Andrea Hospital, Rome, Italy; the †Liver and Multivisceral Transplantation Unit, University of Bologna, Bologna, Italy; and ‡Liver Transplantation, Cleveland Clinic, Cleveland, Ohio Surgery is the only effective treatment able to improve survival of patients with hilar chol- angiocarcinoma (CCA). However, the significance of prognostic factors on overall survival is still debated. We evaluated early and long-term outcomes of patients resected for hilar chol- angiocarcinoma over a 3-year period to determine the role of prognostic factors and their effect on overall survival. Medical records of patients with hilar CCA who underwent resection between January 2001 and December 2004 were retrospectively reviewed. Univariate and multivariate analysis was performed to identify prognostic factors associated with survival. Thirty-two of 45 patients underwent surgical resection with curative intent. Morbidity was 24.4 per cent; peri- operative mortality was 0 per cent. Overall median survival was 22.3 months. Well-differentiated tumor grading and R0 resection were independently associated with better survival at multivar- iate analysis. Aggressive surgery, including biliary resection combined with major hepatectomy, is a safe procedure with low morbidity and mortality in a tertiary referral hepatobiliary center. The main aim of an aggressive surgical approach is to obtain a microscopic margin-negative resection, which is associated with better prognosis. Another important prognostic factor is tumor grading, which is independently associated with survival. H ILAR CHOLANGIOCARCINOMA (CCA) is an un- common malignancy, with an estimated incidence of 1.2 per 100,000 in males and 0.8 per 100,000 in fe- males. It accounts for 6 per cent of all primary hep- atobiliary tumors and is the most common cancer among the neoplasms of the biliary tree, representing 40 to 60 per cent of all cholangiocarcinomas. 1–3 Aggres- sive hepatectomy combined with bile duct resection and extended lymphadenectomy remains the cornerstone of the treatment and represents the only known means to improve survival of patients with hilar bile duct carci- noma. Although recent studies have shown improved survival with extrahepatic bile duct resection combined with hepatectomy, the locoregional recurrence rate is still approximately 40 per cent 4–7 ; furthermore, ag- gressive hepatectomies are associated with higher morbidity and mortality rates compared with those ob- served after resection for hepatocellular carcinoma or liver metastases. However, recent research has demon- strated that patients undergoing margin-negative re- section (R0) have the most favorable prognosis; to accomplish this objective, a major hepatectomy with caudate lobectomy, en bloc resection of the extrahepatic bile duct, portal vein and hepatic artery resection, and regional lymph node dissection is frequently needed. The use of extensive hepatic resections is still debated, especially for patients with impaired general conditions or poor liver function or with Bismuth-Corlette (B-C) Type I or II tumors, because in these cases, a negative resection margin may also be obtained with extrahepatic bile ducts resection alone. The purpose of this study is to analyze the peri- operative and survival outcomes of a homogeneous series of patients treated with aggressive surgical re- section in two hepatobiliary centers over a short period of 3 years. The overall and disease-free survival rates were determined, and an analysis of prognostic factors Address correspondence and reprint requests to Giuseppe Nigri, M.D., Ph.D., Sapienza University of Rome, II School of Medicine, Hepatobiliary Surgery 5EST, St. Andrea Hospital, Via di Grottarossa, 1035-39, 00189 Rome, Italy. E-mail: giuseppe.nigri@uniroma1.it. 1260