Minimally invasive surgery for perihilar cholangiocarcinoma: a systematic review

Feasibility Assessment of Robotic Major Hepatectomy and Bile Duct Resection in Klatskin Type IIIB Tumor with Concomitant Gallbladder Cancer

BACKGROUND

Radical resection is the only curative treatment for perihilar cholangiocarcinoma (Klatskin tumor), the most common type of bile duct cancer.1,2 Because Klatskin tumors require major hepatectomy including segment 1, extensive lymphadenectomy, and bile duct reconstruction, laparoscopic surgery has technical challenges, especially with small and multiple bile ducts.2-5 The robotic platform has great freedom of movement, making it effective for dissection and suturing in minimally invasive Klatskin tumor resection.2,3,6 However, few cases have been reported, prompting this video demonstration.

METHODS

A 74-year-old woman was referred to surgery after biliary drainage due to obstructive jaundice. Adenocarcinoma was diagnosed via endobiliary brushing, with magnetic resonance imaging and computed tomography (CT) showing a polypoid mass in the gallbladder and a 3-cm enhancing mass in the perihilar area. No signs of distant metastasis were present. Thus, robotic left hepatectomy including segment 1, partial hepatectomy of segment 5, and bile duct resection were performed (see video).

RESULTS

The total operative time was 419 min, with an estimated blood loss of 300 ml. Computed tomography on postoperative day 5 showed no abnormal findings, and the patient was discharged on postoperative day 10 without complications. The final pathologic results confirmed the double primary adenocarcinomas with clear resection margins of 6.4 cm and 3.8 cm, respectively, and 11 lymph nodes all were negative for malignancy.

CONCLUSIONS

This case exemplifies the safety and effectiveness of robotic surgery for Klatskin tumors, even with concomitant gallbladder cancer, and demonstrates the benefits and potential of this technique in complex surgical procedures.

Evaluation of the outcomes of biliary-enteric reconstruction in robotic radical resection of hilar cholangiocarcinoma: a single-center propensity score matching analysis

Although robotic radical resection for hilar cholangiocarcinoma (HCCA) has been reported in some large hepatobiliary centers, biliary-enteric reconstruction (BER) remains a critical step that hampers the operation's success. This study aimed to evaluate the feasibility and quality of BER in robotic radical resection of HCCA and propose technical recommendations. A retrospective study was conducted on patients with HCCA who underwent minimally invasive radical resection at Zhejiang Provincial People's Hospital between January 2016 and July 2023. A 1:2 propensity score matching (PSM), widely used to reduce selection bias, was performed to evaluate the outcomes, especially BER-related data, between the robotic and laparoscopic surgery. Forty-six patients with HCCA were enrolled; ten underwent robotic-assisted resection, while the others underwent laparoscopic surgery. After PSM at a ratio of 1:2, 10 and 20 patients were assigned to the robot-assisted and laparoscopic groups, respectively. The baseline characteristics of both groups were generally well-balanced. The average liver resection time was longer in the robotic group than in the laparoscopic group (139.5 ± 38.8 vs 108.1 ± 35.8 min, P = 0.036). However, the former had less intraoperative blood loss [200 (50-500) vs 310 (100-850) ml], despite no statistical difference (P = 0.109). The number of residual bile ducts was 2.6 ± 1.3 and 2.7 ± 1.2 (P = 0.795), and anastomoses were both 1.6 ± 0.7 in the two groups (P = 0.965). The time of BER was 38.4 ± 13.6 and 59.1 ± 25.5 min (P = 0.024), accounting for 9.9 ± 2.8% and 15.4 ± 4.8% of the total operation time (P = 0.001). Although postoperative bile leakage incidence in laparoscopic group (40%) was higher than that in robotic group (10%), there was no significant difference between the two groups (P = 0.204); 6.7 ± 4.4 and 12.1 ± 11.7 days were observed for tube drawing (P = 0.019); anastomosis stenosis and calculus rate was 10% and 30% (P = 0.372), 0% and 15% (P = 0.532), respectively. Neither group had hemorrhage- or bile leakage-related deaths. Robotic radical resection for HCCA may offer perioperative outcomes comparable to conventional laparoscopic procedures and tends to be advantageous in terms of anastomosis time and quality. We are optimistic about its wide application in the future with the improvement of surgical techniques and experience.

Robotic Approach for Perihilar Cholangiocarcinoma IIIA Type: Step-by-Step Procedure

BACKGROUND

Perihilar cholangiocarcinoma is a challenging technique to be performed by minimally invasive approach being the type III among the most complex procedure. Nowadays, the robotic approach is gaining increasing interest among the surgical community, and more and more series describing robotic liver resection have been reported. However, few cases of minimally invasive Bismuth type IIIA cholangiocarcinoma have been reported. Robotic approach allows for a better dissection and suture thanks to the flexible and precise instruments movements, overcoming some of the limitations of the laparoscopic technique. Therefore, robotic technique can facilitate some of the critical steps of a technically demanding procedure, such as the extended right hepatectomy for perihilar cholangiocarcinoma Bismuth IIIA type.

METHODS

In this multimedia video we describe, for the first time in the literature, a full robotic surgical step-by-step technique with some tips and tricks for treating a perihilar cholangiocarcinoma Bismuth IIIA type, performing a radical extended right hemihepatectomy, including segment I combined with regional lymphadenectomy anf left bile duct reconstruction. A 55-year-old woman with obstructive jaundice (10 mg/dl) was referred to our center. The endobiliary brushing confirmed adenocarcinoma, and MRI/CT showed a focal perihilar lesion of 2 cm, including the main biliary duct bifurcation and extending up to the right duct (Bismuth Type IIIA hilar cholangiocarcinoma). After endoscopic biliary stents placement and 6 weeks after right portal vein embolization, the future liver remnant, including segments II and III, reached an enough hypertrophy volume with a ratio of 30%. A right hemihepatectomy with caudate lobe, including standard standard lymphadenectomy and left biliary duct reconstruction was performed.

RESULTS

The operation lasted 670 min with an estimated blood loss of 350 ml. Postoperative pathological examination revealed a moderately differentiated adenocarcinoma pT1N0 with 15 retrieved nodes and free margins. The patient experienced a type A biliary fistula and was discharged on the 21st postoperative day without abdominal drainage.

CONCLUSIONS

Through the tips and tricks presented in this multimedia article, we show the advantages of the robotic approach for performing correctly one of the most complex surgeries.1-7.

Biliary-enteric reconstruction in laparoscopic radical resection of hilar cholangiocarcinoma: a single-center retrospective cohort study

OBJECTIVE

To evaluate the feasibility and quality of biliary-enteric reconstruction (BER) in laparoscopic radical resection of hilar cholangiocarcinoma (LsRRH) versus open surgery and propose technical recommendations.

METHODS

Data of 38 LsRRH and 54 radical laparotomy resections of hilar cholangiocarcinoma (LtRRH) cases were collected from our institution. BER was evaluated via biliary residuals numbers, number of anastomoses, anastomosis manner, suture method, time consumption, and postoperative complication.

RESULTS

In the LsRRH group, patients were relatively younger; Bismuth type I had a higher proportion while type IIIa and IV were less and required no revascularization. In LsRRH and LtRRH groups, respectively, the biliary residuals number was 2.54 ± 1.62 and 2.47 ± 1.46 (p > 0.05); the number of anastomoses was 2.04 ± 1.27 and 2.57 ± 1.33 (p > 0.05); the time of BER was 65.67 ± 21.53 and 42.5 ± 19.77 min (p < 0.05), 15.08 ± 3.64% and 11.76 ± 2.54% of the total operation time (p < 0.05); postoperative bile leakage incidence was 15.79% and 16.67% (p > 0.05); 14 ± 10.28 and 17 ± 9.73 days for healing (p < 0.05); anastomosis stenosis rate was 2.63% and 1.85% (p > 0.05). Neither group had a biliary hemorrhage or bile leakage-related death.

CONCLUSION

The selection bias in LsRRH mainly affects tumor resection than BER. Our cohort study indicates that BER in LsRRH is technically feasible and equals anastomotic quality to open surgery. However, its longer and a more significant proportion of total operation time represent that BER has higher technical requirements and is one of the critical rate-limiting steps affecting the minimal invasiveness of LsRRH.

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).

Pure robotic major hepatectomy with biliary reconstruction for hepatobiliary malignancies: first European results

BACKGROUND

Combined liver and bile duct resection with biliary reconstruction for hepatobiliary malignancies are defined as highly complex surgical procedures. The robotic platform may overcome some major limitations of conventional laparoscopic surgery for these complex cases but its precise role is however still to be defined.

METHODS

In our institution, patients requiring major hepatectomy with biliary reconstruction for malignancies were consecutively selected for minimally invasive robotic surgery from September 2020. All surgeries were undertaken using the da Vinci Xi Surgical System® (Intuitive Surgical, Sunnyvale, CA, USA). Intra-operative technique and postoperative outcome were analyzed.

RESULTS

A total number of 10 patients (3 males and 7 females, median age 72 years) underwent robotic major hepatectomy and bile duct resection for hepatobiliary malignancies between September 2020 and March 2022. The indication for surgery was perihilar cholangiocarcinoma in 5 of 10 patients. Median operative time was 338 min and median blood loss was 110 mL. Postoperative length of stay was between 3 and 16 days (median: 9 days). There was no postoperative 90-day mortality.

CONCLUSIONS

A robotic approach for hepatobiliary malignancies requiring combined major hepatectomy and bile duct resection seems feasible and safe in experienced hands.

Current Perspectives on the Surgical Management of Perihilar Cholangiocarcinoma

Cholangiocarcinoma (CCA) represents nearly 15% of all primary liver cancers and 2% of all cancer-related deaths worldwide. Perihilar cholangiocarcinoma (pCCA) accounts for 50-60% of all CCA. First described in 1965, pCCAs arise between the second-order bile ducts and the insertion of the cystic duct into the common bile duct. CCA typically has an insidious onset and commonly presents with advanced, unresectable disease. Complete surgical resection is technically challenging, as tumor proximity to the structures of the central liver often necessitates an extended hepatectomy to achieve negative margins. Intraoperative frozen section can aid in assuring negative margins and complete resection. Portal lymphadenectomy provides important prognostic and staging information. In specialized centers, vascular resection and reconstruction can be performed to achieve negative margins in appropriately selected patients. In addition, minimally invasive surgical techniques (e.g., robotic surgery) are safe, feasible, and provide equivalent short-term oncologic outcomes. Neoadjuvant chemoradiation therapy followed by liver transplantation provides a potentially curative option for patients with unresectable disease. New trials are needed to investigate novel chemotherapies, immunotherapies, and targeted therapies to better control systemic disease in the adjuvant setting and, potentially, downstage disease in the neoadjuvant setting.

Robotic hepatectomy and biliary reconstruction for perihilar cholangiocarcinoma: a pioneer western case series

Open surgery is the standard of care for perihilar cholangiocarcinoma (pCCA). With the aim of oncologic radicality, it requires a complex major hepatectomy with biliary reconstruction. The postoperative course is consequently often complicated, with severe morbidity and mortality rates of up to 27.5–54% and 18%, respectively. Robotic liver surgery is emerging as a safe, minimally-invasive technique with huge potential for pCCA management. After the first case described by Giulianotti in 2010, here we present the first western series of robot-assisted liver resections with biliary reconstruction for pCCA with the aim to preliminarily assess the feasibility and repeatability of the procedure. At our high-volume teaching hospital center dedicated to HPB surgery, 128 pCCA patients have been surgically treated in the last 15 years whereas more than 800 laparoscopic liver resections have been performed. Since the Da Vinci Xi Robotic platform was introduced in late 2018, 6 major robotic liver resections with biliary reconstruction have been performed, 4 of which were for pCCA. All 4 cases involved a left hepatectomy with caudate lobectomy. The median operating time was 840 min, with a median blood loss of 700 ml. One case was converted to open surgery during the reconstruction due to a short mesentery preventing the hepatico-jejunostomy. None of the patients experienced major complications, while minor complications occurred in 3 out of 4 cases. One biliary leak was managed conservatively. The median postoperative stay was 9 days. Negative biliary margins were achieved in 3 of the 4 cases. An included video clip shows the most relevant technical details. This preliminary series demonstrates that robot-assisted liver resection for pCCA is feasible. We speculate that the da Vinci platform has a relevant potential in pCCA surgery with particular reference to the multi-duct biliary reconstruction. Further studies are needed to better clarify the role of this high-cost technology in the minimally-invasive treatment of pCCA.

Minimally invasive versus open radical resection surgery for hilar cholangiocarcinoma: Comparable outcomes associated with advantages of minimal invasiveness

Background

Minimally invasive surgery (MIS) provides a new approach for patients with hilar cholangiocarcinoma (HCCA). However, whether it can achieve similar outcomes to traditional open surgery (OS) remains controversial.

Methods

To assess the safety and feasibility of MIS for HCCA, a systematic review and meta-analysis was performed to compare the outcomes of MIS with OS. Seventeen outcomes were assessed.

Results

Nine studies involving 382 patients were included. MIS was comparable in blood transfusion rate, R0 resection rate, lymph nodes received, overall morbidity, severe morbidity (Clavien–Dindo classification > = 3), bile leakage rate, wound infection rate, intra-abdominal infection rate, days until oral feeding, 1-year overall survival, 2-year overall survival and postoperative mortality with OS. Although operation time was longer (mean difference (MD) = 93.51, 95% confidence interval (CI) = 64.10 to 122.91, P < 0.00001) and hospital cost (MD = 0.68, 95% CI = 0.03 to 1.33, P = 0.04) was higher in MIS, MIS was associated with advantages of minimal invasiveness, that was less blood loss (MD = -81.85, 95% CI = -92.09 to -71.62, P < 0.00001), less postoperative pain (MD = -1.21, 95% CI = -1.63 to -0.79, P < 0.00001), and shorter hospital stay (MD = -4.22, 95% CI = -5.65 to -2.80, P < 0.00001).

Conclusions

The safety and feasibility of MIS for HCCA is acceptable in selected patients. MIS is a remarkable alternative to OS for providing comparable outcomes associated with a benefit of minimal invasiveness and its application should be considered more.

Surgical Therapy for Perihilar Cholangiocarcinoma: State of the Art

BACKGROUND

Surgical therapy still offers the only chance of long-term survival for patients with perihilar cholangiocarcinoma (pCCA). The aim of this narrative review is to summarize the current standards and challenges in the surgical treatment of pCCA.

SUMMARY

After imaging and defining resectability, the first step towards optimal surgical treatment is optimizing biliary drainage and preventing cholangitis, followed by securing adequate future liver remnant volume and/or function. The main goal of resection for pCCA is achieving radical resection and ultimately long-term survival. In order to achieve radical resection, several points will be addressed (e.g., vascular resection and reconstruction, intraoperative frozen sections, right versus left hemihepatectomy, and the usefulness of preoperative [chemo]therapy).

KEY MESSAGES

In order to optimize long-term outcomes for patients with pCCA, collaboration between leading centers should be increased. In addition, this collaboration is necessary to design large prospective randomized controlled trials, as the incidence of pCCA is low and the number of resectable patients is even lower. Currently, most results are based on small retrospective cohort studies resulting in low evidence. In order to properly investigate how to improve long-term survival, we need to set up trials to confirm the results of small series suggesting the positive effect of preoperative chemotherapy and extended lymph node resection.

Robot-assisted and open resections for perihilar cholangiocarcinoma. Comparative analysis of the immediate outcomes

Background. Minimally invasive radical surgery for perihilar cholangiocarcinoma is in its early stages. Aim. A comparative analysis of the initial experience of robot-assisted and open resections for perihilar cholangiocarcinoma. Material and methods. The single-center experience, accumulated over the period from 2014 to 2018, is analyzed. Robot-assisted procedures included major liver resection and caudate lobectomy with extrahepatic bile duct resection and lymphadenectomy. The need for vascular reconstruction was considered a contraindication to surgery. Results. Thirteen robot-assisted resections were performed. The perihilar cholangiocarcinoma was confirmed by pathologic examination in 10 patients. The immediate outcomes were compared with that in 88 open procedures. There were no significant differences in blood loss, the rate of severe morbidity, mortality, and hospital stay. The duration of the robot-assisted surgical resections was significantly longer. Conclusion. Analysis of initial experience justifies the robotic approach for radical resection in highly selected patients.

Minimally invasive surgery for hilar cholangiocarcinoma: a multicenter retrospective analysis of 158 patients

BACKGROUND

Curative resection of hilar cholangiocarcinoma (HC) is typically carried out using open surgery. In the present study, we examined the safety (postoperative complication) and effectiveness (resection margin status and patient survival) of minimally invasive surgery (MIS) for HC.

METHODS

This retrospective analysis included 158 patients receiving MIS for HC at 10 participating centers between December 2013 and November 2019. Patient demographics, surgical outcomes, and oncological outcomes were retrospectively analyzed.

RESULTS

Clinical information obtained from 10 different clinical centers did not show any evident cohort-bias clustering. One hundred and twenty-six (79.7%) patients underwent LRHC, 12 (7.6%) patients underwent RARHC, conversion to an open procedure occurred in 20 (12.7%) patients. The operation time and estimated blood loss were 410.8 ± 128.9 min and 477.8 ± 706.3 mL, respectively. The surgical radicality of the 158 patients was R0, 129 (81.6%); R1, 20 (18.4%) and R2, 9 (5.7%). Grades I-II complications was occurred in 68 (43.0%) patients. Severe morbidity (grade III-V) occurred in 14 (8.7%) patients. The median overall survival in whole cohort was 25.4 months. The overall survival rate was 67.6% at year 1, 28.8% at year 3, and 19.2% at year 5. Comparing the first half of MISHC performed by each center with the following cases, the operation time and postoperative hospital stay does not decrease with the increasing cases. On literature review, MISHC is non-inferior to open surgery at least in perioperative period.

CONCLUSIONS

In this Chinese MIS for HC multicenter study, the largest to date, long-term overall survival rates after MIS appear comparable to those reported in current open series. Further randomized controlled trials are necessary to assess the global impact of MISHC.

Total Laparoscopic Resection of Hilar Cholangiocarcinoma Type 3b: Applying a Parachute Technique for Hepaticojejunostomy

Background

Laparoscopic liver resection for perihilar cholangiocarcinoma (pCCA) is still in its infancy. The biliary-enteric reconstruction represents one of the most delicate parts of this minimally invasive procedure.

Methods

In this study, a 78-year old woman with perihilar cholangiocarcinoma (pCCA) type 3b underwent a hepaticojejunostomy performed by a parachute technique.

Results

The operation, performed totally by minimally invasive resections, was completed in 386 min, with a blood loss of less than 400 ml and no transfusion requirements. Two intraluminal stents were placed during the hepaticojenunostomy for splinting of the biliary-enteric anastomosis. The patient required prolonged antibiotic treatment for postoperative cholangitis and finally was discharged on postoperative day 15. The histopathologic grading displayed a G 2–3 adenocarcinoma, pT3 pN0, M0, L1, V1, pN1, UICC IIIc R0, and the patient was referred to adjuvant chemotherapy.

Conclusion

Resections of pCCAs, performed totally by minimally invasive techniques, may be feasible and safe for a selected group of patients. With this approach, a running-suture hepaticojejunostomy using the parachute technique represents a worthwhile strategy for biliary-enteric reconstruction.

Electronic supplementary material

The online version of this article (10.1245/s10434-020-09175-1) contains supplementary material, which is available to authorized users.

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.