Does caudate lobe resection really improve the surgical outcomes of patients with hilar cholangiocarcinoma? A multicenter retrospective study.

In the field of hilar cholangiocarcinoma (HCCA) treatment, the value of caudate lobe resection (CLR) has not been fully elucidated. Most scholars advocate that the caudate lobe should be routinely resected. To further investigate this issue, this study aims to evaluate the impact of CLR on surgical outcomes of HCCA patients who are judged to have no obvious tumor invasion in the caudate lobe. A retrospective analysis was performed on Bismuth type II, III, or IV HCCA patients who underwent radical resection between October 2005 and April 2023 at three Chinese medical centers. Patients were divided into the CLR group and the no caudate lobe resection (No-CLR) group according to whether CLR was performed or not. Baseline and tumor characteristics as well as perioperative outcomes were compared between the two groups using propensity score matching (PSM). A total of 397 HCCA patients underwent radical resection and there were 146 patients in each group after PSM. After PSM, the mortality was similar between the two groups. However, patients in the CLR group had a higher incidence of postoperative ascites (43.8% vs 30.1%, P=0.021), liver failure (15.8% vs 6.2%, P=0.014) and intra-abdominal infection (19.2% vs 8.2%, P=0.010). The R0 rate in the CLR group was significantly higher than that in the No-CLR group (88.4% vs 76.0%, P=0.009). Nevertheless, patients undergoing CLR did not show any improvement in overall survival (OS) or recurrence-free survival (RFS). Multivariate analysis showed that CLR was not associated with improved long-term surgical outcomes. The high level of CA19-9 and lower tumor differentiation were associated with worse OS, and adjuvant therapy can significantly improve OS. Lower tumor differentiation and N2 were associated with worse RFS. In summary, there is not yet sufficient evidence to support the routine resection of the caudate lobe during surgery for HCCA. For patients without obvious tumor invasion in the caudate lobe, resection of the lobe should be carefully weighed for its benefits and risks.