Laparoscopic resections for hilar cholangiocarcinomas: a critical appraisal

Safety and feasibility of laparoscopic radical resection for bismuth types III and IV hilar cholangiocarcinoma: a single-center experience from China

Background

Surgery represents the only cure for hilar cholangiocarcinoma (HC). However, laparoscopic radical resection remains technically challenging owing to the complex anatomy and reconstruction required during surgery. Therefore, reports on laparoscopic surgery (LS) for HC, especially for types III and IV, are limited. This study aimed to evaluate the safety and feasibility of laparoscopic radical surgery for Bismuth types III and IV HC.

Methods

The data of 16 patients who underwent LS and 9 who underwent open surgery (OS) for Bismuth types III and IV HC at Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, between December 2017 and January 2022 were analyzed. Basic patient information, Bismuth-Corlette type, AJCC staging, postoperative complications, pathological findings, and follow-up results were evaluated.

Results

Sixteen patients underwent LS and 9 underwent OS for HC. According to the preoperative imaging data, there were four cases of Bismuth type IIIa, eight of type IIIb, and four of type IV in the LS group and two of type IIIa, four of type IIIb, and three of type IV in the OS group (P>0.05). There were no significant differences in age, sex, ASA score, comorbidity, preoperative percutaneous transhepatic biliary drainage rate, history of abdominal surgery, or preoperative laboratory tests between the two groups (P>0.05). Although the mean operative time and mean intraoperative blood loss were higher in the LS group than in OS group, the differences were not statistically significant (P=0.121 and P=0.115, respectively). Four patients (25%) in the LS group and two (22.2%) in the OS group experienced postoperative complications (P>0.05). No significant differences were observed in other surgical outcomes and pathologic findings between the two groups. Regarding the tumor recurrence rate, there was no difference between the groups (P>0.05) during the follow-up period (23.9 ± 13.3 months vs. 17.8 ± 12.3 months, P=0.240).

Conclusion

Laparoscopic radical resection of Bismuth types III and IV HC remains challenging, and extremely delicate surgical skills are required when performing extended hemihepatectomy followed by complex bilioenteric reconstructions. However, this procedure is generally safe and feasible for hepatobiliary surgeons with extensive laparoscopy experience.

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.

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.

Current Advances in Minimally Invasive Surgical Management of Perihilar Cholangiocarcinoma

BACKGROUND

While the safety of minimally invasive surgery (MIS) has been reported for several liver malignancies, the role of MIS in the management of perihilar cholangiocarcinoma (pCCA) has been poorly defined.

METHODS

A systematic review of the literature was performed utilizing MEDLINE/PubMed and Web of Science databases up to January 2020 to assess the safety and feasibility of MIS in the management of patients with pCCA.

RESULTS

Limited data exist on the MIS approach to treat pCCA. Staging laparoscopy carries a low diagnostic yield and typically is used only in select patients with high suspicion of metastatic disease. Data on the use of MIS approach for resection of pCCA have largely been limited to case reports or small case series. A MIS approach to pCCA resection has been demonstrated to be feasible and safe, yet in most series the surgeon failed to include resection of the caudate lobe. Given that caudate lobe involvement occurs in 31-98% of patients with pCCA, incomplete resection of the caudate lobe may be associated with higher local recurrence. More recently, several surgeons have reported complete R0 surgical with removal of the caudate lobe using a MIS approach. While patients may have a shorter length-of-stay, the true benefit of the MIS approach for pCCA needs to be better defined.

CONCLUSIONS

MIS may be a safe and feasible approach at high-volume centers with robust expertise in the management of patients with pCCA. Further studies with larger number of patients are required prior to universal application of MIS for pCCA.

Laparoscopic resection for Bismuth type III and IV hilar cholangiocarcinoma: How to improve the radicality without direct palpation

BACKGROUND

Open surgery for hilar cholangiocarcinoma (HCCA) has already been widely reported and analyzed. However, the laparoscopic technique for treating HCCA remains controversial because of the lack of radicality and poor assessment of the resectability of hilar structures without direct palpation. The aim of this study was to provide detailed surgical procedures and photographs of this technically demanding operation, describe our experience in assessing resectability before and during surgery, and confirm the radicality of laparoscopic resection of Bismuth type III and IV HCCA.

METHODS

From November 2016 to November 2018, nine patients received laparoscopic resection of Bismuth type III or IV HCCA in our department.

RESULTS

Laparoscopic right hepatectomy was performed in four patients, and laparoscopic left hepatectomy was performed in five patients. Negative margins were achieved in all patients. Complications were found in two (22.22%) patients, with bile leakage and hepatic insufficiency each in one patient. The patient developing hepatic insufficiency had persistent and ongoing liver failure and finally expired.

CONCLUSION

The radicality of laparoscopic resection for Bismuth type III and IV HCCA can be technically improved through extended lymphadenectomy, visual assessment of hilar structures, and frozen section techniques.

Extending resectability of hilar cholangiocarcinomas: how can it be assessed and improved?

Until the 1980's, Klatskin tumors were considered 'desperate cases' and most of them were not resected; almost no oncologic concept was available. After many improvements, today, extended hepatectomy, including caudate lobe resection and lymphoadenectomy, have become a standard of care for oncologicaly radical resection of Klatskin tumors. Portal vein en bloc resection, if necessary, is a diffused standard assuring R0-resection without any improvement of survival in most series. Arterial resection remains episodical and controversial in its oncologic impact. Arterial resection-reconstruction was demonstrated to be feasible with many different technical possibilities. Neoadjuvant chemotherapy, refinement of associating liver partition and portal vein ligation for staged hepatectomy and liver transplantations are some possible future resources for treatment of those aggressive tumors that could be able to expand the pool of treatable patients.

Robotic radical resection for hilar cholangiocarcinoma: perioperative and long-term outcomes of an initial series

BACKGROUND

Radical resection for hilar cholangiocarcinoma (HCa) is one of the most challenging abdominal procedures. Robotic-assisted approach is gaining popularity in hepatobiliary surgery but scarcely tried in the management of HCa. We herein report our initial experience of robotic radical resection for HCa.

METHODS

Between May 2009 and October 2012, 10 patients underwent fully robotic-assisted radical resection for HCa in a single institute. The perioperative and long-term outcomes were analyzed and compared with a contemporaneous 32 patients undergoing traditional open surgery.

RESULTS

The 10 patients presented one of Bismuth-Corlette type II, four of IIIa, one of IIIb and four of IV. There was no significant clinicopathological disparity between the robotic and open groups. The robotic radical resection involves hemihepatectomy plus caudate lobectomy or trisectionectomy, extrahepatic bile duct resection, radical lymphadenectomy and Roux-en-Y hepaticojejunostomy. No conversion to laparotomy occurred. Robotic resection compared unfavorably to traditional open resection in operative time (703 ± 62 vs. 475 ± 121 min, p < 0.001) and morbidity [90 (9/10) vs. 50 %, p = 0.031]. No significant difference was found in blood loss, mortality and postoperative hospital stay. Major complications (≥Clavien-Dindo III) occurred in three patients of robotic group. One patient died of posthepatectomy liver failure on postoperative day 18. The hospital expenditure was much higher in robotic group (USD 27,427 ± 21,316 vs. 15,282 ± 5957, p = 0.018). The tumor recurrence-free survival was inferior in robotic group (p = 0.029).

CONCLUSIONS

Fully robotic-assisted radical resection for HCa is technically achievable in experienced hands and should be limited to highly selective patients. Our current results do not support continued practice of robotic surgery for HCa, until significant technical and instrumental refinements are demonstrated.

Laparoscopic resection of hilar cholangiocarcinoma

Laparoscopic resection of hilar cholangiocarcinoma is technically challenging because it involves complicated laparoscopic procedures that include laparoscopic hepatoduodenal lymphadenectomy, hemihepatectomy with caudate lobectomy, and hepaticojejunostomy. There are currently very few reports describing this type of surgery. Between August 2014 and December 2014, 5 patients underwent total laparoscopic or laparoscopic-assisted surgery for hilar cholangiocarcinoma. Two patients with type I or II hilar cholangiocarcinoma underwent radical hilar resection. Three patients with type IIIa or IIIb cholangiocarcinoma underwent extended hemihepatectomy together with caudate lobectomy. The median (range) age, operation time, blood loss, and length of hospital stay were 63 years (43-76 years), 610 minutes (410-665 minutes), 650 mL (450-1,300 mL), and 12 days (9-21 days), respectively. Four patients had a negative margin, but 1 patient was diagnosed with high-grade dysplasia on the proximal resection margin. The median tumor size was 3.0 cm. One patient experienced postoperative biliary leakage, which resolved spontaneously. Laparoscopic resection is a feasible surgical approach in selected patients with hilar cholangiocarcinoma.

Laparoscopy in the management of hilar cholangiocarcinoma

The use of minimally invasive surgery has become widely accepted in many gastrointestinal fields, even in patients with malignancy. However, performing laparoscopic resection for the treatment of hilar cholangiocarcinoma is still not universally accepted as an alternative approach to open surgery, and only a limited number of such procedures have been reported due to the difficulty of performing oncologic resection and the lack of consensus regarding the adequacy of this approach. Laparoscopy was initially limited to staging, biopsy and palliation. Recent technological developments and improvements in endoscopic procedures have greatly expanded the applications of laparoscopic liver resection and lymphadenectomy, and some reports have described the use of laparoscopic or robot-assisted laparoscopic resection for hilar cholangiocarcinoma as being feasible and safe in highly selected cases, with the ability to obtain an adequate surgical margin. However, the benefits of major laparoscopic surgery have yet to be conclusively proven, and carefully selecting patients is essential for successfully performing this procedure.

Current position of ALPPS in the surgical landscape of CRLM treatment proposals

The Authors summarize problems, criticisms but also advantages and indications regarding the recent surgical proposal of associating liver partition and portal vein ligation (PVL) for staged hepatectomy (ALPPS) for the surgical management of colorectal liver metastases. Looking at published data, the technique, when compared with other traditional and well established methods such as PVL/portal vein embolisation (PVE), seems to give real advantages in terms of volumetric gain of future liver remnant. However, major concerns are raised in the literature and some questions remain unanswered, preliminary experiences seem to be promising. The method has been adopted all over the world over the last 2 years, even if oncological long-term results remain unknown, and benefit for patients is questionable. No prospective studies comparing traditional methods (PVE, PVL or classical 2 staged hepatectomy) with ALPPS are available to date. Technical reinterpretations of the original method were also proposed in order to enhance feasability and increase safety of the technique. More data about morbidity and mortality are also expected. The real role of ALPPS is, to date, still to be established. Large clinical studies, even if, for ethical reasons, in well selected cohorts of patients, are expected to better define the indications for this new surgical strategy.