The role of staging laparoscopy in hepatobiliary malignancy: prospective analysis of 401 cases

Gallbladder cancer: surgical treatment, immunotherapy, and targeted therapy

Gallbladder cancer is a common type of biliary tract tumor. Optimal management for early stage cases typically involves radical excision as the primary treatment modality. Various surgical techniques, including laparoscopic, robotic, and navigational surgery, have demonstrated favorable clinical outcomes in radical gallbladder excision. Unfortunately, most patients are ineligible for surgical intervention because of the advanced stage of the disease upon diagnosis. Consequently, non-surgical interventions, such as chemotherapy, radiotherapy, immunotherapy, and targeted therapy, have become the mainstay of treatment for patients in advanced stages. This review focuses on elucidating various surgical techniques as well as advancements in immunotherapy and targeted therapy in the context of recent advancements in gallbladder cancer research.

Surgical management, including the role of transplantation, for intrahepatic and peri-hilar cholangiocarcinoma

Intrahepatic and peri-hilar cholangiocarcinoma are life threatening disease with poor outcomes despite optimal treatment currently available (5-year overall survival following resection 20-35%, and <10% cured at 10-years post resection). The insidious onset makes diagnosis difficult, the majority do not have a resection option and the high recurrence rate post-resection suggests that occult metastatic disease is frequently present. Advances in perioperative management, such as ipsilateral portal vein (and hepatic vein) embolisation methods to increase the future liver remnant volume, genomic profiling, and (neo)adjuvant therapies demonstrate great potential in improving outcomes. However multiple areas of controversy exist. Surgical resection rate and outcomes vary between centres with no global consensus on how 'resectable' disease is defined - molecular profiling and genomic analysis could potentially identify patients unlikely to benefit from resection or likely to benefit from targeted therapies. FDG-PET scanning has also improved the ability to detect metastatic disease preoperatively and avoid futile resection. However tumours frequently invade major vasculo-biliary structures, with resection and reconstruction associated with significant morbidity and mortality even in specialist centres. Liver transplantation has been investigated for very selected patients for the last decade and yet the selection algorithm, surgical approach and both value of both neoadjuvant and adjuvant therapies remain to be clarified. In this review, we discuss the contemporary management of intrahepatic and peri-hilar cholangiocarcinoma.

Laparoscopic ultrasonography along with staging laparoscopy as a tool for staging in patients with hepatopancreaticobiliary malignancy - A prospective cohort study from a tertiary care centre

INTRODUCTION

Staging laparoscopy (SL) plays an important role in avoiding unnecessary non-therapeutic laparotomy in radiologically resectable hepatopancreaticobiliary (HPB) malignancy patients. The limitation of SL is to detect deep-seated malignancy. The addition of laparoscopic ultrasonography for identifying metastatic lesions or locally unresectable disease improves the diagnostic yield of SL.

PATIENTS AND METHODS

This prospective, observational study was conducted in a single unit of the tertiary care centre between 2017 and 2019. All the patients of HPB malignancy who were radiologically resectable underwent SL and laparoscopic intraoperative ultrasonography. Metastatic disease patients were either underwent palliative bypass procedures or abandoned depending on the condition of the patient. Patients who had resectable disease underwent standard surgical procedures.

RESULTS

Forty patients of HPB malignancy with potentially resectable on radiological imaging underwent SL and diagnostic ultrasonography. Out of 40, 21 patients had periampullary, 14 had carcinoma gallbladder and 5 patients had distal cholangiocarcinoma. Metastatic lesions were identified on laparoscopy in eight patients and the diagnostic yield of SL is 20%. Addition of laparoscopic ultrasonography identified one haemangioma which was false positive on laparoscopy and underwent the radical standard procedure. Four patients were unresectable so the procedure was abandoned and another three patients underwent a bypass procedure.

CONCLUSION

Laparoscopic ultrasonography during SL can detect deep-seated metastatic lesions and decide the management in resectable disease.

British Society of Gastroenterology guidelines for the diagnosis and management of cholangiocarcinoma

These guidelines for the diagnosis and management of cholangiocarcinoma (CCA) were commissioned by the British Society of Gastroenterology liver section. The guideline writing committee included a multidisciplinary team of experts from various specialties involved in the management of CCA, as well as patient/public representatives from AMMF (the Cholangiocarcinoma Charity) and PSC Support. Quality of evidence is presented using the Appraisal of Guidelines for Research and Evaluation (AGREE II) format. The recommendations arising are to be used as guidance rather than as a strict protocol-based reference, as the management of patients with CCA is often complex and always requires individual patient-centred considerations.

Annals of Surgical Oncology Practice Guidelines Series: Management of Primary Liver and Biliary Tract Cancers

Primary cancers of the liver and biliary tract are rare and aggressive tumors that often present with locally advanced or metastatic disease. For patients with localized disease amenable to resection, surgery typically offers the best chance at curative-intent therapy. Unfortunately, the incidence of recurrence even after curative-intent surgery remains high. In turn, patients with hepatobiliary cancers commonly require multimodality therapy including a combination of resection, systemic therapy (i.e., targeted therapy, cytotoxic chemotherapy, immunotherapy), and/or loco-regional therapies. With advancements in the field, it is crucial for surgical oncologists to remain updated on the latest guidelines and recommendations for surgical management and optimal patient selection. Given the complex and evolving nature of treatment, this report highlights the latest practice guidelines for the surgical management of hepatobiliary cancers.

The Role of Staging Laparoscopy for Intrahepatic Cholangiocarcinoma: A Snapshot of the Current Literature

Background: Accurate preoperative workup is crucial to identify patients with intrahepatic cholangiocarcinoma (IHC) who would have truly benefit from liver resection, avoiding it in patients with advanced disease or distant metastases. Staging laparoscopy (SL) may prevent unnecessary laparotomies in those patients with otherwise resectable disease, but evidence of its efficacy is scarce and inconclusive. We aimed to aggregate the available evidence dealing with this specific field of research to produce a snapshot of the current knowledge systematically reviewing the inherent literature. Methods: PubMed/Medline, EMBASE, and Web of Sciences electronic databases were queried through December 2022. Inclusion criteria considered all articles reporting data about the role of SL for patients with a diagnosis of IHC. The main outcomes were as follows: overall yield and sensitivity of SL. Results: A total of 5 studies including 119 patients met the inclusion criteria and were included in the analysis. Overall, the yield of SL was 19.6% (11.4%-36%), and the sensitivity was 65.2% (55%-71%). Conclusions: The role of SL for patients with a preoperative diagnosis of IHC remains unclear. The lack of criteria and indications to perform SL for IHC raises the need for international consensus on this specific field of research.

The diagnostic value of staging laparoscopy in gallbladder cancer: a nationwide cohort study

BACKGROUND

Disseminated disease (DD) is often found at (re-)exploration in gallbladder cancer (GBC) patients. We aimed to assess the yield of staging laparoscopy (SL) and identify predictors for DD.

METHODS

This retrospective study included patients from all Dutch academic centres with primary GBC (pGBC) and incidentally diagnosed GBC (iGBC) planned for (re-)resection. The yield of SL was determined. In iGBC, predictive factors for DD were assessed.

RESULTS

In total, 290 patients were included. Of 183 included pGBC patients, 143 underwent laparotomy without SL, and 42 (29%) showed DD perioperatively. SL, conducted in 40 patients, identified DD in eight. DD was found in nine of 32 patients who underwent laparotomy after SL. Of 107 included iGBC patients, 100 underwent laparotomy without SL, and 19 showed DD perioperatively. SL, conducted in seven patients, identified DD in one. Cholecystitis (OR = 4.25; 95% CI 1.51-11.91) and primary R1/R2 resection (OR = 3.94; 95% CI 1.39-11.19) were independent predictive factors for DD.

CONCLUSIONS

In pGBC patients, SL may identify DD in up to 20% of patients and should be part of standard management. In iGBC patients, SL is indicated after primary resection for cholecystitis and after initial R1/R2 resection due to the association of these factors with DD.

Treatment of Intrahepatic Cholangiocarcinoma-A Multidisciplinary Approach

Simple Summary

This review discusses multimodality treatment strategies for intrahepatic cholangiocarcinoma (iCC). Surgical resection remains the only potentially curative therapeutic option and the central cornerstone of treatment. Adjuvant systemic treatment will be recommended after resection or in the palliative setting. Increasing knowledge of phenotypic subclassification and molecular profiling allows investigation of targeted therapies as (neo-)adjuvant treatment. High-dose brachytherapy, internal radiation therapy, and transarterial chemoembolization are among the interventional treatment options being evaluated for unresectable iCC. Given the multiple options of multidisciplinary management, any treatment strategy should be discussed in a multidisciplinary tumor board and treatment should be directed by a specialized treatment center.

Abstract

Intrahepatic cholangiocarcinoma (iCC) is distinguished as an entity from perihilar and distal cholangiocarcinoma and gallbladder carcinoma. Recently, molecular profiling and histopathological features have allowed further classification. Due to the frequent delay in diagnosis, the prognosis for iCC remains poor despite major technical advances and multimodal therapeutic approaches. Liver resection represents the therapeutic backbone and only curative treatment option, with the functional residual capacity of the liver and oncologic radicality being deciding factors for postoperative and long-term oncological outcome. Furthermore, in selected cases and depending on national guidelines, liver transplantation may be a therapeutic option. Given the often advanced tumor stage at diagnosis or the potential for postoperative recurrence, locoregional therapies have become increasingly important. These strategies range from radiofrequency ablation to transarterial chemoembolization to selective internal radiation therapy and can be used in combination with liver resection. In addition, adjuvant and neoadjuvant chemotherapies as well as targeted therapies and immunotherapies based on molecular profiles can be applied. This review discusses multimodal treatment strategies for iCC and their differential use.

Surgical management of intrahepatic cholangiocarcinoma

INTRODUCTION

Intrahepatic cholangiocarcinoma (ICC) incidence continues to rise worldwide, and overall survival remains poor. Complete surgical resection remains the only opportunity for cure in patients with ICC yet only one-third of patients present with resectable disease.

AREAS COVERED

While the low incidence rate of ICC hinders accrual of patients to large, randomized control trials, larger database and long-term institutional studies provide evidence to guide surgical management of ICC. These studies demonstrate feasibility, safety, and efficacy of aggressive surgical management in appropriately selected patients with ICC. Recent advances in the management of ICC, with a focus on surgical considerations, are reviewed.

EXPERT OPINION

Historically, little progress has been made in the management of ICC with stagnant mortality rates and poor long-term outcomes. However, regionalization of care to centers with experienced multidisciplinary teams, advances in minimally invasive surgical techniques, discovery and development of targeted and immunotherapy agents, and combination locoregional and systemic therapies offer signs of progress in the management of ICC.

Challenges and Opportunities for Treating Intrahepatic Cholangiocarcinoma

Intrahepatic cholangiocarcinoma (ICC) is one of the rarest and most aggressive types of cancer. The symptoms of ICC patients can be vague, leading to late diagnosis and dismal prognosis. In this review, we investigated the treatment options for ICC, as well as ways to overcome challenges in identifying and treating this disease. Imaging remains the gold standard to diagnose ICC. Patients are staged based on the tumor, nodes and metastases (TNM) staging system. Patients eligible for surgical resection should undergo surgery with curative intent with the goal of microscopically disease-free margins (R0 resection) along with lymphadenectomy. Minimal invasive surgery (MIS) and liver transplantation have recently been offered as possible ways to improve disease outcomes. ICC recurrence is relatively common and, thus, most patients will need to be treated with systemic therapy. Several clinical trials have recently investigated the use of neoadjuvant (NT) and adjuvant therapies for ICC. NT may offer an opportunity to downsize larger tumors and provide patients, initially ineligible for surgery, with an opportunity for resection. NT may also treat occult micro-metastatic disease, as well as define tumor biology prior to surgical resection, thereby decreasing the risk for early postoperative recurrence. Adjuvant systemic therapy may improve outcomes of patients with ICC following surgery. Ongoing clinical trials are investigating new targeted therapies that hold the hope of improving long-term outcomes of patients with ICC.

Safety and Efficacy of Laparoscopic Caudate Lobectomy: A Systematic Review

Resection of the caudate lobe of the liver is considered a highly challenging type of liver resection due to the region’s intimacy with critical vascular structures and deep anatomic location inside the abdominal cavity. Laparoscopic resection of the caudate lobe is considered one of the most challenging laparoscopic liver procedures. The objective of our systematic review was to evaluate the safety, technical feasibility and main outcomes of laparoscopic caudate lobectomy LCL. A systematic review of the literature was undertaken for studies published until September 2021. A total of 20 studies comprising 221 patients were included. Of these subjects, 36% were women, whereas the vast majority of resections (66%) were performed for malignant tumors. Tumor size varied significantly between 2 and 160 mm in the largest diameter. The mean operative time was 210 min (range 60–740 min), and estimated blood loss was 173.6 mL (range 50–3600 mL). The median hospital length of stay LOS was 6.5 days (range 2–15 days). Seven cases of conversion to open were reported. The vast majority of patients (93.7%) underwent complete resection (R0) of their tumors. Thirty-six out of 221 patients developed postoperative complications, with 5.8% of all patients developing a major complication (Clavien–Dindo classification ≥ III).No perioperative deaths were reported by the included studies. LCL seems to be a safe and feasible alternative to open caudate lobectomy OCL in selected patients when undertaken in high-volume centers by experienced surgeons.

Liver Resection for Intrahepatic Cholangiocarcinoma-Single-Center Experience with 286 Patients Undergoing Surgical Exploration over a Thirteen Year Period

Background: Intrahepatic cholangiocarcinoma (iCCA) accounts for about 10% of primary liver cancer. Surgery is the only potentially curative treatment. We report on our current series of 229 consecutive hepatic resections for iCCA, which is one of the largest Western single-center series published so far. Methods: Between January 2008 to December 2020, a total of 286 patients underwent 307 surgical explorations for intended liver resection of iCCA at our department. Data were analyzed with regard to (1) preoperative treatment of tumor, (2) operative details, (3) perioperative morbidity and mortality, (4) histopathology, (5) outcome measured by tumor recurrence, treatment of recurrence and survival and (6) prognostic factors for overall and disease-free survival. Results: the resectability rate was 74.6% (229/307). In total, 202 primary liver resections, 21 repeated, 5 re-repeated, and 1 re-re-repeated liver resections were performed. In primary liver resections there were 77% (155/202) major hepatectomies. In 39/202 (20%) of patients additional hepatic wedge resections and in 87/202 (43%) patients additional 119 other surgical procedures were performed next to hepatectomy. Surgical radicality in first liver resections was 166 R0-, 33 R1- and 1 R2-resection. Following the first liver resection, the calculated 1-, 3- and 5-year-survival is 80%, 39%, and 22% with a median survival of 25.8 months. Until the completion of data acquisition, tumors recurred in 123/202 (60.9%) patients after a median of 7.5 months (range 1–87.2 months) after resection. A multivariate cox regression revealed tumor size (p < 0.001), T stage (p < 0.001) and N stage (p = 0.003) as independent predictors for overall survival. N stage (p = 0.040), preoperative therapy (p = 0.005), T stage (p = 0.004), tumor size (p = 0.002) and M stage (p = 0.001) were independent predictors for recurrence-free survival. Conclusions: For complete surgical removal, often extended liver resection in combination with complex vascular or biliary reconstruction is required. However, despite aggressive surgery, tumor recurrence is frequent and long-term oncological results are poor. This indicated that surgery alone is unlikely to make great strides in improving prognosis of patients with iCCA, instead clearly suggesting that liver resection should be incorporated in multimodal treatment concepts.

Intrahepatic cholangiocarcinoma: Introducing the preoperative prediction score based on preoperative imaging

BACKGROUND

Intrahepatic cholangiocarcinoma (ICC) still has a poor long-term outcome, even after complete resection. We investigated different parameters gathered in preoperative imaging and analyzed their influence on resectability, recurrence, and survival.

METHODS

All patients who underwent exploration due to ICC between January 2008 and June 2018 were analyzed retrospectively. Kaplan-Meier model, log-rank test and Cox regression were used.

RESULTS

Out of 184 patients, 135 (73.4%) underwent curative intended resection. Median overall survival (OS) was 22.2 months with a consecutive 1-, 3- and 5-year OS of 73%, 29%, and 17%. Median recurrence-free survival (RFS) was 9.3 months with a consecutive 1-, 3- and 5-year RFS of 36%, 15%, and 11%. Site of tumor, parenchymal localization, tumor configuration/dissemination, and estimated tumor volume had significant influence on resectability. Univariate analyses showed that site of tumor, tumor configuration/dissemination, number of nodules, and estimated tumor volume had predictive values for OS and RFS. Together with tumor size the preoperative prediction (POP) score was created showing significance for OS and RFS (all P < 0.001). In multivariate analysis, POP score (HR = 1.779; 95% CI: 1.268-2.495; P = 0.001), T stage (HR = 1.255; 95% CI: 1.040-1.514; P = 0.018) and N stage (HR = 1.334; 95% CI: 1.081-1.645; P = 0.007) were the independent predictors for OS. For RFS, POP score (HR = 1.733; 95% CI: 1.300-2.311; P < 0.001) and M stage (HR = 3.036; 95% CI: 1.376-6.697; P = 0.006) were the independent predictors.

CONCLUSIONS

The POP score showed to have a highly significant influence on OS and RFS. The score is easy to assess through preoperative imaging. For patients in the high risk group at least staging laparoscopy or preoperative chemotherapy should be evaluated, because they showed equal outcome compared to the irresectable group.

Laparoscopic biopsy and staging for locally advanced pancreatic cancer: experiences of 76 consecutive patients in a single institution

BACKGROUND

Pathological diagnosis plays a critical role in the treatment of locally advanced pancreatic cancer (LAPC). However, the commonly used biopsy methods still have a number of shortcomings, such as a relatively low diagnostic accuracy and a high incidence of complications.

METHODS

A retrospective review was conducted to compare 76 patients with laparoscopic biopsy and staging and 11 patients with CT-guided pancreatic biopsy for LAPC between January 2017 and October 2020. Logistic regression with univariate and multivariate analyses was performed to identify preoperative predictors of occult metastasis.

RESULTS

The diagnostic accuracy of laparoscopic biopsy and staging for pancreatic cancer was 100%. Sixty-two patients were confirmed to have LAPC, 59 patients by pancreatic biopsy and three patients by regional lymph node biopsy. Fourteen patients were diagnosed with distant occult metastasis, three patients by liver biopsy and 11 patients by peritoneum biopsy. Nine patients with severe obstructive manifestations underwent a simultaneous bypass procedure. No postoperative hemorrhage, pancreatic fistula, intra-abdominal infection, or trocar site metastasis was observed. Laparoscopic biopsy and staging had a higher diagnostic accuracy (100% vs. 81.8%, p=0.0147) and a shorter duration to chemotherapy (3 days vs. 9 days, p=0.035) than CT-guided biopsy. Elevated CA125 levels (≥35 U/ml) were a significant preoperative predictor of occult metastasis (OR 6.482, 95% CI 1.624-25.874, p=0.008).

CONCLUSIONS

Laparoscopic biopsy and staging are safe and effective methods to obtain rapid pathology and precise staging for LAPC patients, especially for patients with elevated CA125 levels.

Surgical Treatment of Intrahepatic Cholangiocarcinoma: Current and Emerging Principles

Intrahepatic cholangiocarcinoma (ICC) is a rare, aggressive cancer of the biliary tract. It often presents with locally advanced or metastatic disease, but for patients with early-stage disease, surgical resection with negative margins and portahepatis lymphadenectomy is the standard of care. Recent advancements in ICC include refinement of staging, improvement in liver-directed therapies, clarification of the role of adjuvant therapy based on new randomized controlled trials, and advances in minimally invasive liver surgery. In addition, improvements in neoadjuvant strategies and surgical techniques have enabled expanded surgical indications and reduced surgical morbidity and mortality. However, recurrence rates remain high and more effective systemic therapies are still necessary to improve recurrence-free and overall survival. In this review, we focus on current and emerging surgical principals for the management of ICC including preoperative evaluation, current indications for surgery, strategies for future liver remnant augmentation, technical principles, and the role of neoadjuvant and adjuvant therapies.

Italian Clinical Practice Guidelines on Cholangiocarcinoma - Part II: Treatment

Currently, the only curative treatment for cholangiocarcinoma (CCA) is surgical resection, though this treatment is possible in less than 40% of patients. However, recent improvements in preoperative management have led to a higher number of patients who are candidates for this procedure. For unresectable patients, progress is ongoing in terms of locoregional and chemoradiation treatments and target therapies, especially in the definition of patient selection criteria. This is the second part of the Italian CCA guidelines, dealing with CCA treatment, that have been formulated in accordance with Italian National Institute of Health indications and developed according to the GRADE method and related advancements.

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.

Gallbladder Cancer: Managing the Incidental Diagnosis

Managing patients with incidental gallbladder cancer requires stratifying patients risk for recurrence and an appreciation for the recurrence patterns characterizing this malignancy. Although standard management includes reresection to remove sites at risk of harboring residual disease and to achieve negative resection margin status, the decision to perform surgery is tempered by an early and frequent distant recurrence, the most common cause of surgical failure. High-risk patients may benefit from neoadjuvant chemotherapy before reresection. The goal of curative-intent reresection is achieving R0 margin status and optimal staging while limiting morbidity and mortality.

Primary Liver Cancers: Intrahepatic Cholangiocarcinoma and Hepatocellular Carcinoma

The incidence of liver cancers has continued to increase over the past few decades and mortality related to liver cancer has increased by more than 2% annually since 2007. This article reviews the essential workup and treatment options necessary for general surgeons as they treat patients with primary liver cancers.

Relevance of suspicious lymph nodes in preoperative imaging for resectability, recurrence and survival of intrahepatic cholangiocarcinoma

BACKGROUND

Intrahepatic cholangiocarcinoma (ICC) is often diagnosed at an advanced stage resulting in a low resectability rate. Even after potentially curative resection the risk for tumor recurrence is high. Although the extent and value of lymphadenectomy is part of ongoing discussion, the role of preoperative imaging for assessment of suspicious lymph nodes (suspLN) has only been studied modestly. Aim of this study is to demonstrate the influence of suspicious lymph nodes in preoperative imaging on resectability, recurrence, and long-term outcome.

METHODS

All patients who underwent exploration for ICC between January 2008 and June 2018 were included. Preoperative imaging (CT or MRI) was analysed with focus on suspLN at the hepatoduodenal ligament, lesser curvature, interaortocaval, and superior to the diaphragm; suspLN were classified according to the universally accepted RECIST 1.1 criteria; histopathology served as gold standard.

RESULTS

Out of 187 patients resection was performed in 137 (73.3%), in 50 patients the procedure was terminated after exploration. Overall, suspLN were found preoperatively in 73/187 patients (39%). Comparing patients who underwent resection and exploration only, suspLN were significantly more common in the exploration group (p = 0.011). Regarding lymph node stations, significant differences could be shown regarding resectability: All tumors with suspLN superior to the diaphragm were irresectable. Preoperative imaging assessment showed a strong correlation with final histopathology, especially of suspLN of the hepatoduodenal ligament and the lesser curvature. Sensitivity of suspLN was 71.1%, specificity 90.8%. Appearance of tumor recurrence was not affected by suspLN (p = 0.289). Using a short-axis cut-off of <> 1 cm, suspLN had significant influence on recurrence-free survival (RFS, p = 0.009) with consecutive 1-, 3-, and 5-year RFS of 41, 21, and 15% versus 29, 0, and 0%, respectively. Similarly, 1-, 3- and 5-year overall survival (OS) was 75, 30, and 18% versus 59, 18, and 6%, respectively (p = 0.040).

CONCLUSION

Suspicious lymph nodes in preoperative imaging are predictor for unresectability and worse survival. Explorative laparoscopy should be considered, if distant suspicious lymph nodes are detected in preoperative imaging. Nevertheless, given a sensitivity of only 71.1%, detection of suspicious lymph nodes in the preoperative imaging alone is not sufficient to allow for a clear-cut decision against a surgical approach.

Opportunity Lost? Diagnostic Laparoscopy in Patients with Pancreatic Cancer in the National Surgical Quality Improvement Program Database

BACKGROUND

Routine preoperative staging in pancreas cancer is controversial. We sought to evaluate the rates of diagnostic laparoscopy (DLAP) for pancreatic cancer.

METHODS

We queried the National Surgical Quality Improvement Program for patients with pancreas cancer (2005-2013) and compared groups who underwent DLAP, exploratory laparotomy (XLAP), pancreas resection (RSXN) or therapeutic bypass (THBP). We compared demographics, comorbidities, postoperative complications, 30-day mortality (Chi-square P < 0.05) and trends over time (R² 0-1).

RESULTS

We identified 17,138 patients (RSXN 81.8%, XLAP 16.5%, THBP 8.2%, and DLAP 12.9%), with some having multiple CPT codes. Only 10.3% (n = 1432) of RSXN patients underwent DLAP prior to resection. XLAP occurred in 49.5% of non-RSXN patients, of whom 67.1% had no other operation. The percentage of patients undergoing RSXN increased 20.3% over time (R² 0.81), while DLAP decreased 52.6% (R² 0.92). XLAP patients without other operations decreased from 4.2 to 2.4%, although not linearly (R² 0.31). Only 10.3% of XLAP had a diagnostic laparoscopy as well, leaving nearly 90% of these patients with an exploratory laparotomy without RSXN or THBP.

DISCUSSION

Diagnostic laparoscopy for pancreas malignancy is becoming less common but could benefit a subset of patients who undergo open exploration without resection or therapeutic bypass.

Staging laparoscopy among three subtypes of extra-hepatic biliary malignancy: a 15-year experience from 10 institutions

BACKGROUND

Staging laparoscopy (SL) is used to avoid resection failure and thus increase the curative resection rate. SL utilization in extra-hepatic biliary tumors (EHBT) is variable.

METHODS

Data from 1090 patients with potentially resectable EHBT including gallbladder (GBC), distal (DC), and hilar (HC) subtypes were retrospectively collected from 10 academic centers (2000-2015).

RESULTS

The SL utilization rate increased over time and was significantly higher in GBC than DC and HC. SL yield was 16.8% and did not differ between groups or over time. In patients undergoing attempted resection with prior SL, the curative resection rate did not differ between subtypes. In patients undergoing attempted resection without prior SL, the curative resection rate was less in GBC compared with DC or HC. After matching cohorts by inverse probability weighting, prior SL was associated with curative resection in GBC only (odds ratio [OR], 2.41, 95% CI, 1.36-4.27). On multivariable regression analysis, elevated carbohydrate antigen 19-9 (CA 19-9), low serum albumin, and GBC were strong predictors of distant disease on SL. After categorizing patients undergoing SL into low, intermediate, and high-risk groups based on these parameters, SL yield improved progressively from 10.0% to 19.6% to 52.6%.

CONCLUSIONS

We recommend routine SL for patients with GBC, particularly with elevated CA19-9 level and/or decreased serum albumin.

Resection for intrahepatic cholangiocellular cancer: new advances

Intrahepatic cholangiocarcinoma (ICC) is the second most prevalent primary liver neoplasm after hepatocellular carcinoma (HCC), corresponding to 10% to 15% of cases. Pathologies that cause chronic biliary inflammation and bile stasis are known predisposing factors for development of ICC. The incidence and cancer-related mortality of ICC is increasing worldwide. Most patients remain asymptomatic until advance stage, commonly presenting with a liver mass incidentally diagnosed. The only potentially curative treatment available for ICC is surgical resection. The prognosis is dismal for unresectable cases. The principle of the surgical approach is a margin negative hepatic resection with preservation of adequate liver remnant. Regional lymphadenectomy is recommended at time of hepatectomy due to the massive impact on outcomes caused by lymph node (LN) metastasis. Multicentric disease, tumor size, margin status and tumor differentiation are also important prognostic factors. Staging laparoscopy is warranted in high-risk patients to avoid unnecessary laparotomy. Exceedingly complex surgical procedures, such as major vascular, extrahepatic bile ducts and visceral resections, ex vivo hepatectomy and autotransplantation, should be implemented in properly selected patients to achieve negative margins. Neoadjuvant therapy may be used in initially unresectable lesions in order to downstage and allow resection. Despite optimal surgical management, recurrence is frustratingly high. Adjuvant chemotherapy with radiation associated with locoregional treatments should be considered in cases with unfavorable prognostic factors. Selected patients may undergo re-resection of tumor recurrence. Despite the historically poor outcomes of liver transplantation for ICC, highly selected patients with unresectable disease, especially those with adequate response to neoadjuvant therapy, may be offered transplant. In this article, we reviewed the current literature in order to highlight the most recent advances and recommendations for the surgical treatment of this aggressive malignancy.

Challenges of surgical management of intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (iCCA) is a rare malignancy arising from biliary tract epithelium within bile ducts proximal to the secondary biliary radicles. The majority of patients are diagnosed with locally advanced or metastatic disease at presentation. Surgical resection remains the only potentially curative option, but poses unique challenges due to the large size and aggressive behavior of these tumors. Areas covered: The goal of surgical management of iCCA is margin negative (R0) hepatic resection with preservation of adequate size liver remnant and function. Data regarding role of staging laparoscopy, margin status, portal lymphadenectomy, and vascular resection for iCCA are reviewed. Perioperative systemic therapy may have value, although prospective data have been lacking. Recurrence rates remain high even after R0 resection; among patients with recurrent disease limited to the liver, re-resection or locoregional therapies may play a role. Liver transplantation may be an option for select patients with very early-stage iCCA, although this should be done on a protocol-only basis. Expert commentary: Appropriate preoperative patient selection and surgical technique are paramount to ensure optimal oncologic outcomes for patients with resectable iCCA. Improving systemic and locoregional therapy options may help decrease recurrence rates and improve long-term survival for this aggressive malignancy.

Intrahepatic cholangiocarcinoma: current management and emerging therapies

Intrahepatic cholangiocarcinoma (iCCA) is a malignancy with an increasing incidence and a high-case fatality. While surgery offers the best hope at long-term survival, only one-third of tumors are amenable to surgical resection at the time of the diagnosis. Unfortunately, conventional chemotherapy offers limited survival benefit in the management of unresectable or metastatic disease. Recent advances in understanding the molecular pathogenesis of iCCA and the use of next-generation sequencing techniques have provided a chance to identify 'target-able' molecular aberrations. These novel molecular therapies offer the promise to personalize therapy for patients with iCCA and, in turn, improve the outcomes of patients. Area covered: We herein review the current management options for iCCA with a focus on defining both established and emerging therapies. Expert commentary: Surgical resection remains as an only hope for cure in iCCA patients. However, frequently the diagnosis is delayed till advanced stages when surgery cannot be offered; signifying the urge for specific diagnostic tumor biomarkers and targeted therapies. New advances in genomic profiling have contributed to a better understanding of the landscape of molecular alterations in iCCA and offer hope for the development of novel diagnostic biomarkers and targeted therapies.

Monitoring outcomes in intrahepatic cholangiocarcinoma patients following hepatic resection

Intrahepatic cholangiocarcinoma (iCCA) is one of the fatal gastrointestinal cancers with increasing incidence and mortality. Although surgery offers the only potential for cure in iCCA patients, the prognosis is not optimal with low overall survival rate and high disease recurrence. Hence, adjuvant therapy is generally recommended in the management of high-risk patients. Identifying factors associated with disease recurrence and survival of the iCCA patients after resection will improve understanding of disease prognosis and help in selecting patients who will benefit from surgical resection or stratifying them for clinical trials. Despite development of new methods for early detection of tumor recurrence, effective prognostic models and nomograms, and recent advances in management, significant challenges remain in improving the prognosis of iCCA patients.

Diagnostic accuracy of laparoscopy following computed tomography (CT) scanning for assessing the resectability with curative intent in pancreatic and periampullary cancer

BACKGROUND

Surgical resection is the only potentially curative treatment for pancreatic and periampullary cancer. A considerable proportion of patients undergo unnecessary laparotomy because of underestimation of the extent of the cancer on computed tomography (CT) scanning. Laparoscopy can detect metastases not visualised on CT scanning, enabling better assessment of the spread of cancer (staging of cancer). This is an update to a previous Cochrane Review published in 2013 evaluating the role of diagnostic laparoscopy in assessing the resectability with curative intent in people with pancreatic and periampullary cancer.

OBJECTIVES

To determine the diagnostic accuracy of diagnostic laparoscopy performed as an add-on test to CT scanning in the assessment of curative resectability in pancreatic and periampullary cancer.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, EMBASE via OvidSP (from inception to 15 May 2016), and Science Citation Index Expanded (from 1980 to 15 May 2016).

SELECTION CRITERIA

We included diagnostic accuracy studies of diagnostic laparoscopy in people with potentially resectable pancreatic and periampullary cancer on CT scan, where confirmation of liver or peritoneal involvement was by histopathological examination of suspicious (liver or peritoneal) lesions obtained at diagnostic laparoscopy or laparotomy. We accepted any criteria of resectability used in the studies. We included studies irrespective of language, publication status, or study design (prospective or retrospective). We excluded case-control studies.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed data extraction and quality assessment using the QUADAS-2 tool. The specificity of diagnostic laparoscopy in all studies was 1 because there were no false positives since laparoscopy and the reference standard are one and the same if histological examination after diagnostic laparoscopy is positive. The sensitivities were therefore meta-analysed using a univariate random-effects logistic regression model. The probability of unresectability in people who had a negative laparoscopy (post-test probability for people with a negative test result) was calculated using the median probability of unresectability (pre-test probability) from the included studies, and the negative likelihood ratio derived from the model (specificity of 1 assumed). The difference between the pre-test and post-test probabilities gave the overall added value of diagnostic laparoscopy compared to the standard practice of CT scan staging alone.

MAIN RESULTS

We included 16 studies with a total of 1146 participants in the meta-analysis. Only one study including 52 participants had a low risk of bias and low applicability concern in the patient selection domain. The median pre-test probability of unresectable disease after CT scanning across studies was 41.4% (that is 41 out of 100 participants who had resectable cancer after CT scan were found to have unresectable disease on laparotomy). The summary sensitivity of diagnostic laparoscopy was 64.4% (95% confidence interval (CI) 50.1% to 76.6%). Assuming a pre-test probability of 41.4%, the post-test probability of unresectable disease for participants with a negative test result was 0.20 (95% CI 0.15 to 0.27). This indicates that if a person is said to have resectable disease after diagnostic laparoscopy and CT scan, there is a 20% probability that their cancer will be unresectable compared to a 41% probability for those receiving CT alone.A subgroup analysis of people with pancreatic cancer gave a summary sensitivity of 67.9% (95% CI 41.1% to 86.5%). The post-test probability of unresectable disease after being considered resectable on both CT and diagnostic laparoscopy was 18% compared to 40.0% for those receiving CT alone.

AUTHORS' CONCLUSIONS

Diagnostic laparoscopy may decrease the rate of unnecessary laparotomy in people with pancreatic and periampullary cancer found to have resectable disease on CT scan. On average, using diagnostic laparoscopy with biopsy and histopathological confirmation of suspicious lesions prior to laparotomy would avoid 21 unnecessary laparotomies in 100 people in whom resection of cancer with curative intent is planned.

Determination of Resectability

The nuances of determining resectability for liver tumors can be difficult to navigate, owing to the variety of primary and secondary malignancies involving the liver, the range of patient-specific factors to consider, and the hepatic anatomic and functional variability that seems inevitable. The basic principles, however, are simple;if surgery is deemed appropriate from an oncologic standpoint, the patient is in reasonably good health, and the tumor can be safely removed without compromising the integrity of the future remnant, nearly all patients will be candidates for resection.

Pure laparoscopic pancreatoduodenectomy with initial approach to the superior mesenteric artery

INTRODUCTION

The "artery-first approach" (AFA) to the superior mesenteric artery allows an early assessment of resectability of pancreatic tumours and could improve the benefits of laparoscopy, reducing invasiveness, especially for unresectable tumours.

AIM

To describe our technique of pure laparoscopic pancreatoduodenectomy (PLPD) with the AFA, and to report the surgical outcomes of this procedure in a small series of 12 patients through a retrospective analysis of a prospectively collected database.

MATERIAL AND METHODS

Twelve selected patients underwent elective full laparoscopic pancreatoduodenectomy with the AFA. The technical aspects of the procedure are described in detail and the included images facilitate the understanding of the procedure.

RESULTS

The mean operative time was 300 min (range: 250-540 min). No intraoperative complications were observed. No conversion to laparotomy was necessary. The mean postoperative hospital stay was 18 days (range: 8-42). Mortality was null. There were 3 major complications at the 3rd post-operative month follow-up: 2 patients reporting a grade A pancreatic fistula and one biliary fistula.

CONCLUSIONS

Our work shows that pure laparoscopic pancreatoduodenectomy (PLPD) with the AFA is feasible, in selected patients. The AFA could improve on the advantages of laparoscopy in the identification of unresectable patients, and it also allows early control of vascular structures.

Intrahepatic cholangiocarcinoma: expert consensus statement

An American Hepato-Pancreato-Biliary Association (AHPBA)-sponsored consensus meeting of expert panellists met on 15 January 2014 to review current evidence on the management of intrahepatic cholangiocarcinoma (ICC) in order to establish practice guidelines and to agree on consensus statements. The treatment of ICC requires a coordinated, multidisciplinary approach to optimize survival. Biopsy is not necessary if the surgeon suspects ICC and is planning curative resection, although biopsy should be obtained before systemic or locoregional therapies are initiated. Assessment of resectability is best accomplished using cross-sectional imaging [computed tomography (CT) or magnetic resonance imaging (MRI)], but the role of positron emission tomography (PET) is unclear. Resectability in ICC is defined by the ability to completely remove the disease while leaving an adequate liver remnant. Extrahepatic disease, multiple bilobar or multicentric tumours, and lymph node metastases beyond the primary echelon are contraindications to resection. Regional lymphadenectomy should be considered a standard part of surgical therapy. In patients with high-risk features, the routine use of diagnostic laparoscopy is recommended. The preoperative diagnosis of combined hepatocellular carcinoma and cholangiocarcinoma (cHCC-CC) by imaging studies is extremely difficult. Surgical resection remains the mainstay of treatment, but survival is worse than in HCC alone. There are no adequately powered, randomized Phase III trials that can provide definitive recommendations for adjuvant therapy for ICC. Patients with high-risk features (lymphovascular invasion, multicentricity or satellitosis, large tumours) should be encouraged to enrol in clinical trials and to consider adjuvant therapy. Cisplatin plus gemcitabine represents the standard-of-care, front-line systemic therapy for metastatic ICC. Genomic analyses of biliary cancers support the development of targeted therapeutic interventions.

Role of laparoscopy in patients with peritoneal metastases considered for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC)

BACKGROUND

We hypothesized that diagnostic laparoscopy (DL) was feasible for the evaluation of patients with peritoneal carcinomatosis (PC) undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC).

METHODS

A retrospective review of PC patients treated from January 2010 to April 2013 was conducted. Data on tumor characteristics, treatment details and survival outcomes were extracted and analyzed.

RESULTS

Of the 101 PC patients (mean age 52.9 ± 14.1 years), 73 diagnostic laparoscopies DL (61 concurrent with CRS + HIPEC) were performed in 70 patients whereas 31 patients underwent direct exploratory laparotomy (EL). Complete laparoscopic assessment was possible in 63 cases (86.3%), resulting in 18 exclusions (27.7%) while 10 cases were converted to open due to inadequate laparoscopic visualization. Subsequently, CRS + HIPEC was performed in 85.4% (of 55 selected for HIPEC, DL) versus 74.2% (EL, P value = 0.20). Among those excluded from HIPEC at the initial operation, delayed HIPEC after conversion chemotherapy was achieved in 6 (of 11 with extensive disease, DL). The incidence of grade 3 to 5 complications was 0% DL versus 10% EL (P value = 0.2). There were no port site recurrences at mean follow up of 9.1 ± 8 months.

CONCLUSIONS

Laparoscopy is a feasible technique for selecting patients with PC for CRS + HIPEC, and can help select patients for conversion chemotherapy in the setting of high peritoneal carcinomatosis index (PCI) score.

Current management of colorectal liver metastases

SUMMARY 

Colorectal cancer is common worldwide and is predicted to become more so in the coming years. The liver is the most common site of metastasis and management is increasingly complex. A multidisciplinary team approach to management is essential, and is associated with better outcomes. Patients with irresectable liver metastases can still benefit from the involvement of a liver specialist, as high secondary resection rates can be achieved with combination chemotherapy, incorporating novel biological therapies and liver-directed local and locoregional treatments. The application of an enhanced recovery model to perioperative care, alongside improvements in the assessment of patient fitness for surgery, should help to mitigate the challenges presented by an older population with increased comorbidity undergoing increasingly complex treatment.

Diagnostic accuracy of laparoscopy following computed tomography (CT) scanning for assessing the resectability with curative intent in pancreatic and periampullary cancer

BACKGROUND

Surgical resection is the only potentially curative treatment for pancreatic and periampullary cancer. A considerable proportion of patients undergo unnecessary laparotomy because of underestimation of the extent of the cancer on computed tomography (CT) scanning. Laparoscopy can detect metastases not visualised on CT scanning, enabling better assessment of the spread of cancer (staging of cancer). There has been no systematic review or meta-analysis assessing the role of diagnostic laparoscopy in assessing the resectability with curative intent in patients with pancreatic and periampullary cancer.

OBJECTIVES

To determine the diagnostic accuracy of diagnostic laparoscopy performed as an add-on test to CT scanning in the assessment of curative resectability in pancreatic and periampullary cancer.

SEARCH METHODS

We searched the Cochrane Register of Diagnostic Test Accuracy Studies, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed, EMBASE via OvidSP (from inception to 13 September 2012), and Science Citation Index Expanded (from 1980 to 13 September 2012).

SELECTION CRITERIA

We included diagnostic accuracy studies of diagnostic laparoscopy in patients with potentially resectable pancreatic and periampullary cancer on CT scan, where confirmation of liver or peritoneal involvement was by histopathological examination of suspicious (liver or peritoneal) lesions obtained at diagnostic laparoscopy or laparotomy. We accepted any criteria of resectability used in the studies. We included studies irrespective of language, publication status, or study design (prospective or retrospective). We excluded case-control studies.

DATA COLLECTION AND ANALYSIS

Two authors independently performed data extraction and quality assessment using the QUADAS-2 tool. The specificity of diagnostic laparoscopy in all studies was 1 because there were no false positives since laparoscopy and the reference standard are one and the same if histological examination after diagnostic laparoscopy is positive. Therefore, the sensitivities were meta-analysed using a univariate random-effects logistic regression model. The probability of unresectability in patients who had a negative laparoscopy (post-test probability for patients with a negative test result) was calculated using the median probability of unresectability (pre-test probability) from the included studies and the negative likelihood ratio derived from the model (specificity of 1 assumed). The difference between the pre-test and post-test probabilities gave the overall added value of diagnostic laparoscopy compared to the standard practice of CT scan staging alone.

MAIN RESULTS

Fifteen studies with a total of 1015 patients were included in the meta-analysis. Only one study including 52 patients had a low risk of bias and low applicability concern in the patient selection domain. The median pre-test probability of unresectable disease after CT scanning across studies was 40.3% (that is 40 out of 100 patients who had resectable cancer after CT scan were found to have unresectable disease on laparotomy). The summary sensitivity of diagnostic laparoscopy was 68.7% (95% CI 54.3% to 80.2%). Assuming a pre-test probability of 40.3%, the post-test probability of unresectable disease for patients with a negative test result was 0.17 (95% CI 0.12 to 0.24). This indicates that if a patient is said to have resectable disease after diagnostic laparoscopy and CT scan, there is a 17% probability that their cancer will be unresectable compared to a 40% probability for those receiving CT alone.A subgroup analysis of patients with pancreatic cancer gave a summary sensitivity of 67.9% (95% CI 41.1% to 86.5%). The post-test probability of unresectable disease after being considered resectable on both CT and diagnostic laparoscopy was 18% compared to 40% for those receiving CT alone.

AUTHORS' CONCLUSIONS

Diagnostic laparoscopy may decrease the rate of unnecessary laparotomy in patients with pancreatic and periampullary cancer found to have resectable disease on CT scan. On average, using diagnostic laparoscopy with biopsy and histopathological confirmation of suspicious lesions prior to laparotomy would avoid 23 unnecessary laparotomies in 100 patients in whom resection of cancer with curative intent is planned.

The role of staging laparoscopy in primary gall bladder cancer--an analysis of 409 patients: a prospective study to evaluate the role of staging laparoscopy in the management of gallbladder cancer

OBJECTIVE

To evaluate the role of staging laparoscopy (SL) in the management of gallbladder cancer (GBC).

METHODS

A prospective study of primary GBC patients between May 2006 and December 2011. The SL was performed using an umbilical port with a 30-degree telescope. Early GBC included clinical stage T1/T2. A detectable lesion (DL) was defined as one that could be detected on SL alone, without doing any dissection or using laparoscopic ultrasound (surface liver metastasis and peritoneal deposits). Other metastatic and locally advanced unresectable disease qualified as undetectable lesions (UDL).

RESULTS

Of the 409 primary GBC patients who underwent SL, 95 had disseminated disease [(surface liver metastasis (n = 29) and peritoneal deposits (n = 66)]. The overall yield of SL was 23.2% (95/409). Of the 314 patients who underwent laparotomy, an additional 75 had unresectable disease due to surface liver metastasis (n = 5), deep parenchymal liver metastasis (n = 4), peritoneal deposits (n = 1), nonlocoregional lymph nodes (n = 47), and locally advanced unresectable disease (n = 18), that is, 6-DL and 69-UDL. The accuracy of SL for detecting unresectable disease and DL was 55.9% (95/170) and 94.1% (95/101), respectively. Compared with early GBC, the yield was significantly higher in locally advanced tumors (n = 353) [25.2% (89/353) vs 10.7% (6/56), P = 0.02]. However, the accuracy in detecting unresectable disease and a DL in locally advanced tumors was similar to early GBC [56.0%, (89/159) and 94.1%, (89/95) vs 54.6% (6/11) and 100% (6/6), P = 1.00].

CONCLUSIONS

In the present series with an overall resectability rate of 58.4%, SL identified 94.1% of the DLs and thereby obviated a nontherapeutic laparotomy in 55.9% of patients with unresectable disease and 23.2% of overall GBC patients. It had a higher yield in locally advanced tumors than in early-stage tumors; however, the accuracy in detecting unresectable disease and a DL were similar.

Routine staging laparoscopy has no place in the management of colorectal liver metastases

AIMS

Staging laparoscopy has been recommended in the management of patients with colorectal liver metastases prior to hepatectomy in order to reduce the incidence and associated morbidity of futile laparotomies. The utility of staging laparoscopy has not been assessed in patients undergoing CT, PET-CT and MRI as standard preoperative staging.

METHODS

All patients undergoing attempted open hepatectomy for colorectal liver metastases between 1/4/2008 and 31/3/2012 were identified from a prospectively maintained research database. All patients who underwent futile laparotomy were identified, with demographics and operative notes subsequently analysed.

RESULTS

A total of 274 patients underwent attempted open hepatectomy during the study period. At laparotomy 12 (4.4%) patients were found to have irresectable disease. There were no unifying demographic factors within the patients undergoing futile laparotomy.

CONCLUSIONS

With modern imaging, the potential yield of staging laparoscopy is low. Staging laparoscopy should not be used routinely, but may have a role in the case of specific clinical concerns.

Laparoscopic caudate hepatectomy for cancer--an innovative approach to the no-man's land

BACKGROUND

Caudate hepatectomy remains a surgical challenge in spite of recent advances in laparoscopic technique. Hepatic tumor in the caudate lobe is usually deeply located in the center of the liver and close to the vena cava and hepatic hilum. Thus, lesion in this region was considered as a contraindication of laparoscopic hepatectomy. Only sporadic reports could be found in the literature. The aim of this study is to review the safety and feasibility of laparoscopic hepatectomy for lesions in the caudate lobe.

METHODS

Nine consecutive patients with caudate hepatic tumor received laparoscopic caudate hepatectomy in our institute from February 2006 to July 2010. One patient with hepatic adenoma was excluded from the analysis. Demographic data, intraoperative parameters, and postoperative outcomes of the remaining eight patients were assessed.

RESULTS

All procedure for these eight patients with caudate hepatic tumors (size 0.9-4.5 cm) were completed with totally laparoscopic technique except one in which additional left hepatectomy was also done. The average operative time was 254 min (range 210-345 min) and estimated blood loss was 202 ml (range 10-1,000 ml), and average length of postoperative hospital stay was 6.9 days (range 4-11 days). There was no perioperative complications and patient mortality in this series.

CONCLUSIONS

Our experience demonstrated that laparoscopic hepatectomy is a safe and feasible procedure for caudate hepatic tumors in selected patients.

Comparison of laparoscopic and open intraoperative ultrasonography for staging liver tumours

BACKGROUND

Laparoscopic liver surgery must reproduce open surgical steps. Intraoperative ultrasonography (IOUS) is mandatory, but reliability of laparoscopic IOUS has been poorly evaluated. The aim of this study was to compare laparoscopic versus open IOUS in staging liver tumours.

METHODS

All patients scheduled for liver resection between September 2009 and March 2011 were considered. Inclusion criteria were primary and metastatic tumours. Exclusion criteria were: hilar/gallbladder cholangiocarcinoma, ten or more lesions, repeat resection, laparoscopic hepatectomy, adhesions and unresectability. Following percutaneous ultrasonography and thoracoabdominal computed tomography (CT), and on indication contrast-enhanced (CE) liver magnetic resonance imaging (MRI) and/or positron emission tomography (PET)-CT, patients were scheduled for laparoscopy, laparoscopic IOUS, then laparotomy, open IOUS and Partial hepatectomy. Data were collected prospectively. Reference standards were final pathology and 6-month follow-up results.

RESULTS

Sixty-five patients were included, who had a median of 3 preoperative imaging studies (ultrasonography/CT 100 per cent, CE-MRI 67 per cent, PET-CT 54 per cent). A total of 119 lesions were diagnosed. Laparoscopic IOUS detected 22 additional lesions (+18·5 per cent) in 14 patients. Open IOUS detected two additional lesions, but did not confirm four lesions; overall 20 additional lesions (+16·8 per cent) were detected in ten patients. Pathology confirmed 14 newly detected malignant nodules (+11·8 per cent) in eight patients. After 6 months ten new nodules were identified in six patients. The sensitivity of preoperative imaging, laparoscopic IOUS and open IOUS was 83·1, 92·3 and 93·0 per cent respectively; accuracy was 79, 82 and 88 per cent. In comparison with open IOUS, the sensitivity and accuracy of laparoscopic IOUS were 98·6 and 94 per cent.

CONCLUSION

Laparoscopic IOUS is a reliable tool for staging liver tumours with a performance similar to that of open IOUS in detecting new nodules.

Risk of occult irresectable disease at liver resection for hepatic colorectal cancer metastases: a contemporary analysis

INTRODUCTION

Traditionally, rates of irresectable disease at laparotomy for colorectal liver metastases (CRLM) have ranged from 15 to 70%. Diagnostic laparoscopy has been shown to be effective at preventing nontherapeutic laparotomy in selected patients. The purpose of this study was to analyze the resectability rate and role of diagnostic laparoscopy in a contemporary cohort.

METHODS

Using a prospectively maintained database, we identified patients who were explored for presumed resectable CRLM. Clinical and pathologic data associated with the finding of irresectable disease were analyzed.

RESULTS

From 2008-2010, 455 patients were explored. Of these, 35 (7.7%) did not undergo a resection and/or ablation. Of the 35 patients with irresectable disease, 15 (43%) had disease limited to the liver, 17 (49%) had extrahepatic disease (EHD), and 3 (9%) had other reasons precluding resection. Of the whole cohort, 45 patients (9.9%) were found to have EHD, and 27 of these (60%) underwent complete resection or ablation. The only factor associated with irresectable disease was a prior history of EHD, which was present in 29% of those found irresectable versus 13% of those resected (p = 0.022). Diagnostic laparoscopy was performed in 55 patients. Four of these patients had irresectable disease, and three were spared unnecessary laparotomy. Therefore, the yield was 5% and the sensitivity 75%.

CONCLUSIONS

The finding of irresectable disease is a rare event with modern radiologic assessment and the expansion of indications for resection. Diagnostic laparoscopy has a low yield and should be considered if there is a history of EHD or suspicious findings on preoperative imaging.

Role of diagnostic laparoscopy in assessing operability in borderline resectable gastrointestinal cancers

BACKGROUND:

Diagnostic laparoscopy helps in diagnosing and staging Gastrointestinal (GI) cancers. Routine laparoscopy before laparotomy, especially in cancers that have equivocal operability, helps to avoid unnecessary laparotomies. Present study evaluates utility of laparoscopy in diagnosing and staging GI cancers.

MATERIALS AND METHODS:

Diagnostic laparoscopy was done in 41 patients with gastrointestinal (GI) cancers who were thought to have equivocal operability. Patients with suspected or known non-metastatic GI cancers, in whom resectability was found doubtful by clinical assessment and pre-operative imaging, were included. Patients with non-GI cancers (lymphoma, gynaecologic cancers, genitourinary cancers, retroperitoneal sarcoma, sarcoma and abdominal metastasis of non-GI cancers) and metastatic cancers which were beyond the scope of curative surgery were excluded from the study.

RESULTS:

After diagnostic laparoscopy (DL) five patients had benign diagnosis. Out of 36 patients with malignant diagnosis, after DL, 22 patients (61.1%) were inoperable, 11 patients (30.6%) were operable, and three (8.3%) patients were of equivocal operability. Sensitivity, specificity, positive predictive value, and negative predictive value of laparoscopy in detecting operability were 100%, 91.7%, 81.8%, and 100%, respectively.

CONCLUSIONS:

Laparoscopy helped in a significant number of patients with advanced GI cancers to avoid laparotomy. The morbidity of DL was acceptable.

The introduction of a laparoscopic liver surgery programme: a cost analysis of initial experience in a university hospital

BACKGROUND AND AIMS

In the era of expanding costs of healthcare, this study was conducted to perform a cost analysis of introducing a laparoscopic liver surgery programme for left sided liver lesions.

MATERIALS AND METHODS

Consecutive patients treated by laparoscopic liver resections of left lateral segments were included. Controls were a group of 14 patients undergoing open resection for similar pathology. Primary outcomes were costs. Secondary outcomes were complications, conversions, blood loss, length of operation, and length of hospital stay.

RESULTS

The laparoscopic approach for hepatic left lateral resection (bisegmentectomy 2 and 3) was performed in fourteen patients (group I, median age 54 [range 26-82] years). In the open group, fourteen patients from a prospectively collected database with the same type of resection were selected (group II, median age 64 [range 29-76] years). Costs of theatre usage in the laparoscopic group were significantly lower (p=0.031). No significant differences in costs of disposable instruments, ward stay and total costs were observed between the two groups. There were three complications in the laparoscopic group compared with two complications in the open group. In the laparoscopic group there were 2 conversions (14%). Median blood loss was significantly lower in the laparoscopic group (50 mls [range 0-750], (p=0.001) versus the open group (500 mls [range 150-750]). Furthermore, operation time was also significantly lower in the laparoscopic group (116 [range 85-261] minutes) versus the open group (165 [range 96-217] minutes, p=0.016). Median length of stay was 6 [range 4-11] days in group I versus 6 [range 5-13] days in group II (p=0.508).

CONCLUSION

Costs of laparoscopic liver resections proved to be equivalent to open surgery. Furthermore, implementation of a laparoscopic liver resection programme seems feasible and safe with reduced blood loss and operation time and comparable morbidity and length of stay.

The Blumgart preoperative staging system for hilar cholangiocarcinoma: analysis of resectability and outcomes in 380 patients

BACKGROUND

Complete resection of hilar cholangiocarcinoma (HCCA) is a critical determinant of long-term survival. This study validates a previously reported preoperative clinical T staging system for determining resectability of HCCA.

STUDY DESIGN

Consecutive patients with confirmed HCCA treated over an 18-year period were included. Patient demographics, preoperative imaging studies, resection type, margin status, lymph node status, histopathologic findings, morbidity, and outcomes were entered prospectively and analyzed retrospectively; changes in these variables over time were assessed. All patients were placed into 1 of 3 stages based on the extent of ductal involvement by tumor, portal vein compromise, or lobar atrophy.

RESULTS

From March 1991 through December 2008, 380 patients were evaluated. Eighty-five patients had unresectable disease; 295 patients underwent exploration with curative intent. One hundred fifty-seven patients underwent resection: 129 (82.2%) had a concomitant hepatic resection and 120 (76.4%) had an R0 resection. Of the 32 actual 5-year survivors (120 at risk), 30 patients (93.8%) had a concomitant hepatic resection. In patients who underwent an R0 resection, concomitant partial hepatectomy, well-differentiated histology, and negative lymph nodes were independent predictors of long-term survival. In the 376 patients whose disease could be staged, the preoperative clinical T staging system predicted resectability (p < 0.001), metastatic disease (p < 0.001), and R0 resection (p = 0.007).

CONCLUSIONS

The preoperative clinical T staging system of Blumgart, defined by the radial and longitudinal tumor extent, accurately predicts resectability of HCCA. The full outcomes benefit of resection is realized only if a concomitant partial hepatectomy is performed.

Reappraisal of hepatopancreatoduodenectomy as a treatment modality for bile duct and gallbladder cancer

BACKGROUND

Hepatopancreatoduodenectomy has been performed to achieve radical resection in malignant biliary tumors. We reviewed clinical outcomes to evaluate the clinical feasibility of hepatopancreatoduodenectomy for the treatment of gallbladder and bile duct cancer.

METHODS

Twenty-three patients underwent hepatopancreatoduodenectomy from 1995 to 2007; 10 gallbladder cancer and 13 bile duct cancer. Median follow-up periods were 15.0 months.

RESULTS

R0 resection was performed in 17 of 23 patients (73.9%). Morbidity and mortality rates were 91.3% and 13.0%, respectively. Five-year survival rates were 10.0% for gallbladder cancer and 32.3% for bile duct cancer. Survival more than 3 years was possible for most patients with stage IIA or less, whereas all gallbladder cancer patients with stage III and all bile duct cancer with stage IIB or more died within 2 years. Bile duct cancer patients with pN0 survived longer than those with pN1 (p < 0.001).

CONCLUSIONS

To obtain negative proximal and distal ductal resection margins in the biliary tract cancer, R0 resection and long-term survival can be achieved by hepatopancreatoduodenectomy. However, its adoption in patients with lymph node metastasis or adjacent organ invasion cannot be recommended.