Pure laparoscopic radical resection for type IIIa hilar cholangiocarcinoma

Laparoscopic versus open surgery for perihilar cholangiocarcinoma: a multicenter propensity score analysis of short- term outcomes

BACKGROUND

Laparoscopic surgery (LS) has been increasingly applied in perihilar cholangiocarcinoma (pCCA). In this study, we intend to compare the short-term outcomes of LS versus open operation (OP) for pCCA in a multicentric practice in China.

METHODS

This real-world analysis included 645 pCCA patients receiving LS and OP at 11 participating centers in China between January 2013 and January 2019. A comparative analysis was performed before and after propensity score matching (PSM) in LS and OP groups, and within Bismuth subgroups. Univariate and multivariate models were performed to identify significant prognostic factors of adverse surgical outcomes and postoperative length of stay (LOS).

RESULTS

Among 645 pCCAs, 256 received LS and 389 received OP. Reduced hepaticojejunostomy (30.89% vs 51.40%, P = 0.006), biliary plasty requirement (19.51% vs 40.16%, P = 0.001), shorter LOS (mean 14.32 vs 17.95 d, P < 0.001), and lower severe complication (CD ≥ III) (12.11% vs. 22.88%, P = 0.006) were observed in the LS group compared with the OP group. Major postoperative complications such as hemorrhage, biliary fistula, abdominal abscess, and hepatic insufficiency were similar between LS and OP (P > 0.05 for all). After PSM, the short-term outcomes of two surgical methods were similar, except for shorter LOS in LS compared with OP (mean 15.19 vs 18.48 d, P = 0.0007). A series subgroup analysis demonstrated that LS was safe and had advantages in shorting LOS.

CONCLUSION

Although the complex surgical procedures, LS generally seems to be safe and feasible for experienced surgeons.

TRIAL REGISTRATION

NCT05402618 (date of first registration: 02/06/2022).

The Long-Term Outcome of Laparoscopic Resection for Perihilar Cholangiocarcinoma Compared with the Open Approach: A Real-World Multicentric Analysis

OBJECTIVE

The aim of this study was to compare the short- and long-term outcomes of laparoscopic surgery (LS) and open surgery (OP) for perihilar cholangiocarcinoma (PHC) using a large real-world dataset in China.

METHODS

Data of patients with PHC who underwent LS and OP from January 2013 to October 2018, across 10 centers in China, were extracted from medical records. A comparative analysis was performed before and after propensity score matching (PSM) in the LS and OP groups and within the study subgroups. The Cox proportional hazards mixed-effects model was applied to estimate the risk factors for mortality, with center and year of operation as random effects.

RESULTS

A total of 467 patients with PHC were included, of whom 161 underwent LS and 306 underwent OP. Postoperative morbidity, such as hemorrhage, biliary fistula, abdominal abscess, and hepatic insufficiency, was similar between the LS and OP groups. The median overall survival (OS) was longer in the LS group than in the OP group (NA vs. 22 months; hazard ratio [HR] 1.19, 95% confidence interval [CI] 1.02-1.39, p = 0.024). Among the matched datasets, OS was comparable between the LS and OP groups (NA vs. 35 months; HR 0.99, 95% CI 0.77-1.26, p = 0.915). The mixed-effect model identified that the surgical method was not associated with long-term outcomes and that LS and OP provided similar oncological outcomes.

CONCLUSIONS

Considering the comparable long-term prognosis and short-term outcomes of LS and OP, LS could be a technically feasible surgical method for PHC patients with all Bismuth-Corlett types of PHC.

Preliminary comparison of total laparoscopic and open radical resection for hepatic hilar cholangiocarcinoma a single-center cohort study

BACKGROUD

The aim was to compare perioperative outcomes of hilar cholangiocarcinoma (HCCA) radical resection performed through the laparoscopic route or by open surgery in single-center cohort study.

METHODS

A retrospective study included all patients undergoing HCCA radical resection in our center from January 2018 to November 2019. Short-term outcomes of patients with laparoscopic and open surgery were compared demographic characteristics, intraoperative and postoperative parameters and extent of resection.

RESULTS

Among 64 patients included, 34 were performed with laparoscopic route and 30 were with open surgery. Laparoscopic versus open group was associated with a longer operation duration [475.50(219.00-630.00) vs. 375.00(220.00-557.00) min, P = 0.031], similar intraoperative bleeding volume [300.00(50.00-3500.00) vs. 350.00(100.00-1500.00) ml, P = 0.426]. No significant differences in tumor diameter [2.00(1.50-3.00) vs. 2.00(1.50-3.00) cm, P = 0.965], the number of lymph nodes retrieved [9.50(6.00-15.00) vs. 8.50(5.00-12.00), P = 0.706], and resection margins (94.1% vs. 86.7%, P = 0.407) between the two approaches were found. The LOS [20.00(10.00-44.00) vs. 21.00(6.00-27.00) d, P = 0.622], bile leakage (23.5% vs. 26.7%, P = 0.781), and liver failure (8.80% vs. 6.70%, P>0.99) were similar in the two groups. There was one patient in open surgery group developing liver failure and finally expired.

CONCLUSION

The safety and radicality of laparoscopic resection for HCCA are similar to open surgery and can be technically improved by rational trocar distribution, total caudate lobectomy and appropriate cholangioenteric anastomosis strategy.

Comparison of Efficacy and Safety Between Laparoscopic and Open Radical Resection for Hilar Cholangiocarcinoma-A Propensity Score-Matching Analysis

BACKGROUND

Radical resection remains the most effective treatment for hilar cholangiocarcinoma (HCCA). However, due to the complex anatomy of the hilar region, the tumor is prone to invade portal vein and hepatic arteries, making the surgical treatment of HCCA particularly difficult. Successful laparoscopic radical resection of HCCA(IIIA, IIIB) requires excellent surgical skills and rich experience. Furthermore, the safety and effectiveness of this operation are still controversial.

AIM

To retrospectively analyze and compare the efficacy and safety of laparoscopic and open surgery for patients with HCCA.

METHODS

Clinical imaging and postoperative pathological data of 89 patients diagnosed with HCCA (IIIA, IIIB) and undergoing radical resection in our center from January 2018 to March 2022 were retrospectively analyzed. Among them, 6 patients (4 were lost to follow-up and 2 were pathologically confirmed to have other diseases after surgery) were ruled out, and clinical data was collected from the remaining 83 patients for statistical analysis. These patients were divided into an open surgery group (n=62) and a laparoscopic surgery group (n=21) according to the surgical methods used, and after 1:2 propensity score matching (PSM), 32 and 16 patients respectively in the open surgery group and laparoscopic surgery group were remained. The demographic data, Bismuth type, perioperative data, intraoperative data, postoperative complications, pathological findings, and long-term survivals were compared between these two groups.

RESULTS

After 1:2 PSM, 32 patients in the open surgery group and 16 patients in the laparoscopic surgery group were included for further analysis. Baseline characteristics and pathological outcomes were comparable between the two groups. Statistically significant differences between the two groups were observed in intraoperative blood loss and operative time, as it were 400-800 mL vs 200-400 mL (P=0.012) and (407.97 ± 76.06) min vs (489.69 ± 79.17) min (P=0.001) in the open surgery group and laparoscopic surgery group, respectively. The R0 resection rate of the open group was 28 cases (87.5%), and the R0 resection rate of the laparoscopic group was 15 cases (93.75%). The two groups showed no significant difference in terms of surgical approach, intraoperative blood transfusion, incidence of postoperative complications, and short- and long-term efficacy (P>0.05).

CONCLUSIONS

Laparoscopic radical resection of HCCA has comparable perioperative safety compared to open surgery group, as it has less bleeding and shorter operation time. Although it is a promising procedure with the improvement of surgical skills and further accumulation of experience, further investigations are warranted before its wider application.

A Consensus Meeting on Expert Recommendations on Operating Specifications for Laparoscopic Radical Resection of Hilar Cholangiocarcinoma

Background: With advances in techniques and technologies, laparoscopic radical resection of hilar cholangiocarcinoma (HCCA) has gradually been carried out in major medical centers in China. Its feasibility and safety have been accepted by a group of Chinese surgical experts. Methods: To standardize perioperative management of HCCA by using laparoscopic resectional approach, to ensure safety of the patient with standardized management, improve prognosis of the patient, and enable proper application and refinement of this surgical approach, the expert group on specifications for laparoscopic radical resection of HCCA in China organized a consensus meeting. Results: Laparoscopic radical resection of HCCA is difficult and associated with high risks. Appropriate patients should be carefully selected and this surgical approach should be promoted gradually. The experts met and arrived at 16 recommendations on perioperative management of HCCA by using laparoscopic surgery. There were three recommendations on preoperative diagnosis and evaluation; one recommendation on surgical principles of treatment; one recommendation on indications and contraindications; one recommendation on credentialing, staffing, and equipment; nine recommendations on laparoscopic techniques in different stages of operation; and one recommendation on indications for conversion to open surgery. Conclusion: Laparoscopic surgery for HCCA is still in the early phase of development. This consensus provides a clinical reference with the aim to promote and to facilitate its further development.

Laparoscopic hepatopancreatoduodenectomy for locally advanced gall bladder cancer

Hepatopancreatoduodenectomy (HPD) can offer a survival advantage in selected patients with locally advanced gall bladder cancer (GBC). While the safety and feasibility of minimally invasive radical cholecystectomy have been recently documented, laparoscopic HPD for GBC has not been previously reported. A 73-year-old male with GBC infiltrating the bile duct underwent laparoscopic HPD to achieve R0 resection. The patient had an uneventful post-operative course except for delayed gastric emptying that improved with conservative management. The feasibility of laparoscopic HPD for locally advanced GBC reported in the present case needs to be documented in a large case series.

Systematic review of perioperative and oncologic outcomes of minimally-invasive surgery for hilar cholangiocarcinoma

Most surgeons have traditionally been reluctant toward minimally-invasive surgery for bile duct tumors. This study aimed to perform a systematic literature review on perioperative and oncologic results of pure laparoscopic and robotic curative-intent surgery for hilar cholangiocarcinoma. According to the PRISMA statement, a systematic review was conducted into Pubmed, EMBASE and Cochrane. A critical appraisal of study was performed according to the Joanna Briggs Institute tools. Nineteen studies (12 on pure laparoscopy and 7 on robotics) were included: 7 case reports, 9 case series, 3 case-control (193 patients). The pooled conversion, morbidity, biliary leak and mortality rates were 5.5%, 43%, 16.4% and 4%. The weighted mean of operative time, blood loss and postoperative stay were 388 min, 446 mL and 14 days. For pure laparoscopy, the pooled R0 rate was 86%; overall survival and disease-free survival rates ranged from 85 to 100% and from 80 to 100% (median observation time 6-18 months). For robotic surgeries, the pooled R0 rate was 69% and overall survival rates ranged from 90 to 100% (median observation time 5-15 months). Case reports were overall of high quality, case series of moderate / high-quality, case-control studies ranged from low to high quality. In selected patients, minimally-invasive surgery for Klatskin tumors appears feasible, safe, satisfactory for perioperative outcomes and adequate for oncologic results. However, the results are based on few studies, limited in patient numbers and with allocation criteria more restrictive than open, reporting short follow-up and mainly with non-comparative design: evidence of higher quality is recommended.

Total laparoscopic versus open radical resection for hilar cholangiocarcinoma

BACKGROUND

Radical resection is the only curative option for patients with hilar cholangiocarcinoma (HCCA) to achieve long-term survival. However, due to the fact that radical resection of HCCA has high technical requirements, the safety and efficacy of laparoscopic resection for HCCA remains controversial.

METHOD

From January 2015 to December 2018, 23 cases of HCCA underwent radical resection in our center. Clinical data of those patients were collected and analyzed retrospectively.

RESULTS

14 patients underwent laparoscopic resection and 9 cases received open resection. 2 patients in laparoscopic group were converted to laparotomy. Operation time in laparoscopic group was significantly longer than that in open group (519.4 ± 155.4 min vs 366.7 ± 93.1 min). Estimated blood loss (620.0 ± 681.2 ml vs 821.4 ± 713.8 ml) and incidence of intraoperative blood transfusion (5/9 vs 8/14) did not differ significantly between two groups. Pathological outcomes were comparable between two groups. Length of postoperative hospital stay (23.4 ± 13.4 days vs 17.8 ± 7.1 days), severe postoperative morbidity (3/9 vs 5/14), bile leakage of Grade A or B (5/9 vs 5/14), intra-abdominal bleeding (0/9 vs 1/14), intra-abdominal abscess (1/9 vs 0/14), wound infection (0/9 vs 1/14), pulmonary infection (2/9 vs 0/14), and liver failure (0/9 vs 0/14) did not differ significantly between two groups. One patient in laparoscopic group died (1/14) at 21 postoperative days due to intra-abdominal bleeding, while no 30-day mortality was observed in open group.

CONCLUSION

Our results demonstrate that laparoscopic radical resection of HCCA is safe and feasible in experienced hands. Although laparoscopic resection for HCCA, which is still in initial and exploratory stage, fails to show any advantage over open resection in this study, we are optimistic with its wide application in future with the improvement of surgical techniques and experience.

Complete laparoscopic radical resection of hilar cholangiocarcinoma: technical aspects and long-term results from a single center

Introduction

The landscape of surgical treatments for hepatobiliary disease was significantly changed after the advent of laparoscopy. Many kinds of complex laparoscopic procedures can be routinely performed at present, but radical resection of hilar cholangiocarcinoma (HC) by laparoscopy is still highly contentious.

Aim

To describe our primary experience with laparoscopic radical resection for HC and determine the safety and feasibility of this procedure.

Material and methods

Between December 2015 and November 2019, 32 patients planned to undergo curative-intent laparoscopic resection of HC in our department. The perioperative and long-term outcomes of these patients were retrospectively analyzed.

Results

Laparoscopic surgery with radical resection was ultimately performed in 24 (75.0%) patients; 3 (9.3%) patients were found to be unresectable at the preliminary exploration stage, and 5 (15.7%) patients converted from laparoscopy to laparotomy. The operation time and blood loss were 476.95 ±133.89 min and 568.75 ±324.01 ml, respectively. A negative margin was achieved in 19 (79.1%) of the laparoscopy patients. Three (12.5%) patients were identified with microscopic positive margins, and 2 (8.4%) patients underwent macroscopic residual tumor resection (R2). The length of postoperative stay was 23.3 ±11.7 days. Severe morbidity occurred in 4 (16.6%) patients. The actuarial 3-year overall survival and disease-free survival for patients who underwent laparoscopic surgery were 49.1% and 47.0%, respectively.

Conclusions

Laparoscopic radical resection for HC is safe and feasible in experienced hands for highly selected patients but is still in its initial stages. When adequate oncologic resection is performed, the laparoscopic approach does not adversely influence the prognosis of the patient.

Laparoscopic surgery and robotic surgery for hilar cholangiocarcinoma: an updated systematic review

BACKGROUND

The role of laparoscopic surgery (Lap) and robotic surgery (Rob) for radical resection of hilar cholangiocarcinoma (HC) is not clear. We summarized the safety and feasibility of Lap and Rob for HC.

METHODS

A search of all HC studies in English published on PubMed up to April 2020 was conducted. References from retrieved articles were reviewed to broaden the search.

RESULTS

In total, 23 reports were enrolled: 15 involving Lap, seven using Rob and one study reporting a minimally invasive approach (Lap or Rob, not specified). A total of 205 cases of HC were documented (Lap/Rob/not specified, 99/101/5): 37 cases of Bismuth type-I (Lap/Rob, 17/20), 22 cases of Bismuth type-II (Lap/Rob, 15/7), 68 cases of type-III (Lap/Rob, 39/29) and 13 cases of type-IV (Lap/Rob, 9/4). The pooled prevalence of R0 resection was 80.1% (Lap/Rob, 85.9%/71.0%). The weighted mean for operative time, blood loss and post-operative hospital stay was 458.4 min (Lap/Rob, 423.3/660.8 min), 615.3 mL (Lap/Rob, 521.0/1188.5 mL) and 14.0 days (Lap/Rob, 14.0/13.7 days), respectively. The pooled prevalence of conversion to open surgery, post-operative complications, and perioperative mortality was 9.1% (Lap/Rob, 12.2%/3.8%), 47.2% (Lap/Rob, 38.4%/61.3%) and 3.0% (Lap/Rob, 4.0%/2.0%), respectively.

CONCLUSION

With innovations in technology and gradual accumulation of surgical experience, the feasibility and safety of performing Lap and Rob for HC will improve.

The role of minimally invasive hepatectomy for hilar and intrahepatic cholangiocarcinoma: A systematic review of the literature

Despite the fact laparoscopic liver resections (LLR) for cholangiocarcinoma is still limited, this systematic review addressed surgical and oncological outcomes of LLR to treat both perihilar cholangiocarcinoma (pCCA) and intrahepatic cholangiocarcinoma (iCCA). Five comparative and 20 noncomparative studies were found. Regarding iCCA, LLR had lower blood loss and less need for Pringle maneuver. However, open liver resections (OLR) were performed more for major hepatectomies, with better lymphadenectomy rates and higher number of harvested lymph nodes. High heterogeneity and selection bias were suggested for iCCA studies.

Minimally invasive surgery for perihilar cholangiocarcinoma: a systematic review

Minimally invasive surgery (MIS) is quickly becoming mainstream in hepato-pancreato-biliary surgery because of presumed advantages. Surgery for perihilar cholangiocarcinoma (PHC) is highly demanding which may hamper the feasibility and safety of MIS in this setting. This study aimed to systematically review the existing literature on MIS for PHC. A systematic literature review was performed according to the PRISMA statement. The PubMed and EMBASE databases were searched and all studies describing MIS in patients with PHC were included. Data extraction and risk of bias were assessed by two independent researchers. Overall, 21 studies reporting on a total of 142 MIS procedures for PHC were included. These included 82 laparoscopic, 59 robot-assisted and 1 hybrid procedure(s). Risk of bias was deemed substantial. Pooled conversion rate was 7/142 (4.9%), pooled morbidity 30/126 (23.8%), and pooled mortality rate 4/126 (3.2%). The only comparative study, comparing 10 robot-assisted procedures to 32 open procedures, reported a significant increased operative time and higher morbidity rate with MIS. The available evidence on MIS for PHC is limited and generally of poor quality. This systematic review shows that the implementation of MIS for patients with PHC is still in its infancy.

Reasons for open conversion in robotic liver surgery: A systematic review with pooled analysis of more than 1000 patients

BACKGROUND

Conversion to open during minimally invasive liver resection has a high rate. To identify the reasons to convert could help in defining a strategy to decrease the event "conversion."

METHODS

A systematic review has been performed. Our large series of robotic hepatic resections were analyzed and included in the review.

RESULTS

Fifty papers were selected and carefully evaluated in full text. Twenty-nine were ultimately used for analysis, including all published robotic liver resections. Our series included 11 conversions out of 139 patients (7.9%). Adhesions were not a declared reason to convert. The robotic approach still had a high percentage of open conversions because of difficulties in assessing the tumor margin.

CONCLUSIONS

Causes for conversion were carefully analyzed and compared with what previously described for the pure laparoscopic approach. This could be crucial in defining how to improve the performance and minimize the conversion rate.

Minimally invasive surgery for hilar cholangiocarcinoma: state of art and future perspectives

BACKGROUND

Hilar cholangiocarcinoma (HCCA) occurs in the core section of the biliary system and has a strong tendency to broadly invade the surrounding vascular system, perineural tissue and major liver parenchyma. Thus, minimally invasive resection can only be achieved in limited cases. This article reviews the current laparoscopic and robotic surgery techniques for HCCA and analyses the difficulties and limitations of the current minimally invasive surgical techniques for HCCA.

METHODS

A systematic literature search was conducted using multiple electronic databases. All studies involving minimally invasive resections of HCCA were included (up to November 2017).

RESULTS

Twelve studies were included, of which eight concerned laparoscopic surgery of HCCA and four involved robotic surgery for HCCA. For laparoscopic surgery, most of the surgical procedures were limited to partial hepatectomy or even bile duct resection; the post-operative morbidity rate was approximately 38.9% (range 0-100%); those with fewer complications were mostly restricted to Bismuth type I or type II carcinomas. For robotic surgery, only one study concerned caudate lobectomy of HCCA, with a reported median operative time of 703 min and post-operative morbidity of 90%.

CONCLUSIONS

Minimally invasive surgery for HCCA is restricted to highly selected cases and is deemed technically achievable in experienced hands. However, technical and instrumental improvement is needed to reduce the relevant morbidity and popularize the use of minimally invasive surgery to treat HCCA.

Laparoscopic Left Hepatectomy for Ruptured Hepatocellular Carcinoma Controlled After Transcatheter Arterial Embolization: Case Report and Review of the Literature

BACKGROUND

Although spontaneous tumour rupture is a life-threatening complication of hepatocellular carcinoma (HCC), staged hepatectomy for HCC controlled after transcatheter arterial embolization (TAE) could provide a better prognosis. Laparoscopic liver resection (LLR) has been accepted worldwide and has been expanded from minor resection to anatomical major resection. We herein report the first case of pure laparoscopic left hepatectomy for ruptured HCC controlled after TAE.

CASE REPORT

A 66-year-old man was transferred to our Institute because of abdominal pain and decreased consciousness. Ruptured HCC in segment IV and massive intra-abdominal haemorrhage were diagnosed. Emergency TAE was performed, achieving haemostasis. Reduction of intra-abdominal haemorrhage was confirmed at the 3-month follow-up, and no intrahepatic metastasis or peritoneal dissemination was present. Therefore, we performed elective laparoscopic left hepatectomy for the remaining HCC 110 days after TAE. Although dense adhesion was found in the upper right peritoneal cavity and greater omentum enveloping the remaining haemorrhage on the underside of the liver, there was no disseminated involvement in the peritoneal cavity. The operative time was 194 minutes, and intraoperative blood loss was 100 g. The postoperative course was uneventful, and the patient was discharged on postoperative day 6.

CONCLUSION

Major LLR may be an option for staged hepatectomy in patients with ruptured HCC controlled after TAE.