Cholangiocarcinoma: Are North American Surgical Outcomes Optimal? Andrew P Loehrer, MD, Michael G House, MD, FACS, Attila Nakeeb, MD, FACS, E Molly Kilbane, RN, Henry A Pitt, MD, FACS BACKGROUND: Cholangiocarcinomas are deadly and require complex decisions as well as major surgery. A few referral centers have reported good results, but no robust, risk-adjusted outcomes data are available. The aims of this study were to analyze the surgical outcomes of a very large cohort of patients undergoing operations for cholangiocarcinoma in North America. STUDY DESIGN: The American College of Surgeons National Surgical Quality Improvement Program Partic- ipant Use File was queried for patients with bile duct cancers. Patients (n ¼ 839) were classified as having intrahepatic (36.5%), perihilar (34.4%), or distal (29.1%) cholangiocarcinomas by the type of procedure performed. Observed and expected (O/E) morbidity and mortality rates, O/E indices, and regression-adjusted risk factors were determined. RESULTS: Mortality was highest for perihilar tumors that were managed with hepatectomy and biliary- enteric anastomosis (11.9%) and lowest for distal cholangiocarcinomas (1.2%). After risk adjustment, mortality was considerable greater than expected for patients undergoing hepa- tectomy with biliary-enteric anastomosis (O/E ¼ 3.0) or hepatectomy alone (O/E ¼ 2.4). CONCLUSIONS: This analysis suggests that postoperative outcomes are best for distal and worst for perihilar cholan- giocarcinomas, and hepatectomy for bile duct cancers is associated with a 2- to 3-fold mortality risk. We conclude that North American surgical outcomes can be improved for patients with proximal cholangiocarcinomas. (J Am Coll Surg 2013;216:192e200. Ó 2013 by the American College of Surgeons) Cholangiocarcinoma represents a rare but increasingly common malignancy, accounting for nearly 3% of all gastrointestinal tumors and 10% to 15% of all primary hepatobiliary cancer. 1,2 Approximately 5,000 new patients are diagnosed with cholangiocarcinoma in the United States each year. 3 Survival rates for both intrahepatic and extrahepatic cholangiocarcinoma have improved, but optimal surgical outcomes remain problematic, in large part because of the challenging location of the primary tumors. 4 Overall 5-year survival rates for patients under- going surgical resection range from 10% to 50%, depend- ing on stage, location of tumor, and adequacy of surgical resection. 5 Survival has been shown to improve with R0 surgical resection, yet these procedures remain highly morbid. 6,7 In addition, postoperative complications from resection of hilar cholangiocarcinoma are associated with decreased long-term survival. 8 Most studies to date arise from small single or multi-institutional series. Although previous studies have identified specific factors associated with morbidity from pancreatectomy, data are limited on current outcomes of surgery for cholangiocarcinoma. 9 The primary aim of this study is to analyze the surgical outcomes of patients undergoing operations for cholan- giocarcinoma in a North American cohort. METHODS The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) is a prospective, multicenter clinical registry that was created to provide feedback on risk-adjusted outcomes to hospitals for quality-improvement purposes. The sampling strategy, data abstraction procedures, variables collected, and structure have already been published. 10-13 Through nationally trained surgical clinical reviewers, the program collects detailed information on patient demographics, preoperative risk factors and laboratory CME questions for this article available at http://jacscme.facs.org Disclosure Information: Authors have nothing to disclose. Timothy J Eberlein, Editor-in-Chief, has nothing to disclose. Presented at the International Hepato-Pancreato-Biliary Association Meeting, Paris, France, July 2012. Received September 14, 2012; Revised October 29, 2012; Accepted November 5, 2012. From the Department of Surgery, Indiana University, Indianapolis, IN. Correspondence address: Henry A Pitt, MD, FACS, Department of Surgery, Indiana University, 535 Barnhill Dr, RT 130D, Indianapolis, IN 46202. email: hapitt@iupui.edu 192 ª 2013 by the American College of Surgeons ISSN 1072-7515/12/$36.00 Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jamcollsurg.2012.11.002