Safety and feasibility of laparoscopic liver resection with associated lymphadenectomy for intrahepatic cholangiocarcinoma: a propensity score-based case-matched analysis from a single institution

Laparoscopic Hilar Lymph Node Sampling in Patients With Biliary Tract Cancers That are Rarely Associated With Nodal Metastasis

PURPOSE

Among the various types of biliary tract cancer, patients with single, small (<5 cm), peripheral intrahepatic cholangiocarcinoma (ICC), or small (<2 cm) gallbladder tumors (GBTs) rarely develop lymph node (LN) metastasis. We investigated a laparoscopic approach for hilar LN sampling in such cases.

METHODS

Among the 176 patients with biliary tract cancer who were treated from January 2012 to March 2017, 21 (ICC, n=4; GBT, n=17) met the above indications.

RESULTS

All patients were treated by a laparoscopic approach with R0 resection. After determining the pathologic diagnosis, 9 patients with GBT and all 4 patients with ICC underwent laparoscopic LN sampling; the mean numbers of sampled LNs were 2.6 and 7.3, respectively; no patients had metastasis. The mean operating times for GBT and ICC were 223 and 379 minutes, respectively; the mean blood loss was 23 mL and 171 mL. With the exception of 1 patient who developed intrahepatic metastasis of ICC at the opposite liver lobe, all of the patients were recurrence free.

CONCLUSIONS

A laparoscopic approach could be safely applied under our indications.

Perioperative and Long-Term Outcomes of Laparoscopic Versus Open Lymphadenectomy for Biliary Tumors: A Propensity-Score-Based, Case-Matched Analysis

BACKGROUND

The purpose of this study was to compare patients undergoing MILS and open liver resections with associated lymphadenectomy for biliary tumors (intrahepatic cholangiocarcinoma and gallbladder cancer) in a case-matched analysis using propensity scores.

METHODS

A total of 104 consecutive patients underwent liver resection with associated locoregional lymphadenectomy by laparoscopic approach constituted the study group (MILS group). The MILS group was matched in a ratio of 1:2 with patients who had undergone open resection for primary biliary cancers (Open group). Short- and long-term outcomes were evaluated and compared, with specific focus on specific details of lymphadenectomy.

RESULTS

Laparoscopic series resulted in a statistically significant lower blood loss (200 vs. 350, p = 0.03), minor intraoperative blood transfusions (3.2% vs. 7.9%, p = 0.04), and postoperative blood transfusions (10.5% vs. 15.8%), other than shorter length of stay (4 vs. 6 days, p = 0.04). Number of retrieved nodes was 8 versus 7 (p = not significant); particularly, percentage of patients who achieved the recommended AJCC cutoff of six lymph nodes harvested were 93.7% versus 85.8% (p = 0.05). Both overall and lymphadenectomy-related morbidity (bleeding, pancreatitis, lymphatic fistula, vascular, and biliary injuries) were lower in MILS group (respectively 16.3% and 3.2% vs. 22.1% and 5.3%, p = 0.03). Median disease-free survival was 33 versus 36 months and disease recurrence occurred in 45.3% versus 55.3% of patients in MILS and Open groups respectively.

CONCLUSIONS

Laparoscopic approach for lymphadenectomy is a valid option in patients with biliary cancers, because it allows to maintain the advantages of minimally invasive approach, without compromising the accuracy and the outcomes of nodal dissection.

Long-Term Oncologic Outcomes Following Robotic Liver Resections for Primary Hepatobiliary Malignancies: A Multicenter Study

OBJECTIVE

Robotic liver surgery (RLS) has emerged as a feasible alternative to laparoscopic or open resections with comparable perioperative outcomes. Little is known about the oncologic adequacy of RLS. The purpose of this study was to investigate the long-term oncologic outcomes for patients undergoing RLS for primary hepatobiliary malignancies.

METHODS

We performed an international, multicenter, retrospective study of patients who underwent RLS for hepatocellular carcinoma (HCC), cholangiocarcinoma (CC), or gallbladder cancer (GBC) between 2006 and 2016. Age, gender, histology, resection margin status, extent of surgical resection, disease-free survival (DFS), and overall survival (OS) were retrospectively collected and analyzed.

RESULTS

Of the 61 included patients, 34 (56%) had RLS performed for HCC, 16 (26%) for CC, and 11 (18%) for GBC. The majority of resections were nonanatomical or segmental resections (39.3%), followed by central hepatectomy (18%), left-lateral sectionectomy (14.8%), left hepatectomy (13.1%), right hepatectomy (13.1%), and right posterior segmentectomy (1.6%). R0 resection was achieved in 94% of HCC, 68% of CC, and 81.8% of GBC patients. Median hospital stay was 5 days, and conversion to open surgery was needed in seven patients (11.5%). Grade III-IV Dindo-Clavien complications occurred in seven patients with no perioperative mortality. Median follow-up was 75 months (95% confidence interval 36-113), and 5-year OS and DFS were 56 and 38%, respectively. When stratified by tumor type, 3-year OS was 90% for HCC, 65% for GBC, and 49% for CC (p = 0.01).

CONCLUSIONS

RLS can be performed for primary hepatobiliary malignancies with long-term oncologic outcomes comparable to published open and laparoscopic data.

Minimally Invasive Approaches for Surgical Management of Primary Liver Cancers

The benefits of minimally invasive approaches in oncologic surgery are increasingly recognized, and laparoscopic liver surgery has become increasingly widespread. In light of the complexity and technical challenges of hepatobiliary procedures, robotic approaches are also employed. The utility, safety, and oncologic integrity of these methods in the management of primary liver cancers are reported. PubMed was used to search the medical literature for studies and articles pertaining to laparoscopic and robotic liver surgery. Studies that particularly addressed hepatocellular carcinoma and cholangiocarcinoma were identified and reviewed. Laparoscopic liver surgery, including for major resections, has been shown to be safe in experienced hands without any compromise of oncologic outcomes for either hepatocellular carcinoma or intrahepatic cholangiocarcinoma. Some studies show improved clinical outcomes including shorter hospital stays and lower complication rates when compared to open surgery, particularly for patients with cirrhosis. Robotic liver surgeries seem to have equally acceptable clinical outcomes; however, there is limited data regarding oncologic integrity and considerable additional expense. Laparoscopic and robotic liver resections are both feasible and safe for the management of primary liver tumors. Future studies should aim to clarify specific indications and optimize applications of these approaches.

Diffusion, outcomes and implementation of minimally invasive liver surgery: a snapshot from the I Go MILS (Italian Group of Minimally Invasive Liver Surgery) Registry

The Italian Group of MILS (I Go MILS) prospective registry was established in 2014 with the goals to create a hub for data and projects on a national basis and to promote the diffusion and implementation of MILS programs on a national scale. The primary endpoint of the present study is to give a snapshot of the real diffusion and outcomes of MILS in Italy, while analyzing the role of the registry in the implementation of MILS programs nationwide. The I Go MILS Registry is a prospective and intention-to-treat registry opened to any Italian center performing MILS, without restriction criteria based on number of procedures. The Registry is developed through the eClinical, an electronic platform for the management of clinical trials and is based on 34 clinical variables, regarding indication, intra- and postoperative course. Clinical outcomes and data regarding implementation of MILS activity have been analyzed for the aim of the study. Between November 2014 and June 2017, data from 1678 MILS performed in 48 centers have been collected (mean number of procedures per center 35, range 1-302). 22% of procedures were performed for benign and 78% for malignant disease (HCC constituted the 49.1% and CRLM the 31.2% of malignant tumors). Major liver resections (>3 liver segments), including right and left hepatectomies, trisectionectomies and ALPPS procedures were 10% of the series. Mean blood loss was 200 ± 230 mL Morbidity rate was 20.5% and mortality was 0.3%. 10.4% of cases were converted to open approach. Median length of stay was 5 days. MILS/total resections ratio in 13 experienced centers increased from 14 to 30% after Registry establishment. MILS programs are well established in Italy, with progressive increase both in the number of cases and in the numerosity of centers. The I Go MILS Registry is playing a crucial role in monitoring the development of MILS in the real world on a national basis while giving a significant contribution to the implementation of MILS programs.

Multidisciplinary management of intrahepatic cholangiocarcinoma: Current approaches

Intrahepatic cholangiocarcinoma (ICC) is a common primary hepatic tumor. However, its outcomes are usually worse than those of hepatocellular carcinoma owing to its non-specific presentation and detection at an advanced stage. The most widely used serum marker, carbohydrate antigen 19-9, is non-specific. Furthermore, imaging studies rarely identify any pathognomonic features. Surgery is the only treatment option that offers a chance of long-term survival. However, the resectability rate is low owing to the high frequencies of intrahepatic metastases, peritoneal carcinomatosis, or extrahepatic metastases. Surgical treatment should be tailored according to the macroscopic classification of ICC (e.g. mass-forming, periductal infiltrating, and intraductal growth types) because it reflects the tumor's dissemination pattern. Although lymph node metastasis is a negative prognostic factor, the importance and extent of lymph node dissection is still controversial. To improve patient survival, liver transplantation is considered in some patients with unresectable ICC, especially in those with an insufficient remnant liver volume. Minimally invasive procedures, including laparoscopic and robotic liver resection, have been tested and achieved comparable outcomes to conventional surgery in preliminary studies. No randomized trials have confirmed the efficacy of adjuvant chemotherapy in ICC, and several trials have evaluated molecular-targeted agents as monotherapy or in combination with cytotoxic chemotherapy. Multidisciplinary approaches are necessary to improve the outcomes of ICC.

The role of minimally invasive surgery in the treatment of cholangiocarcinoma

Cholangiocarcinoma (CC) is the second most common type of primary liver cancer after hepatocellular carcinoma. Surgical resection is considered the only curative treatment for CC. In general, laparoscopic liver surgery (LLS) is associated with improved short-term outcomes without compromising the long-term oncological outcome. However, the role of LLS in the treatment of CC is not yet well established. In addition, CC may arise in any tract of the biliary tree, thus requiring different types of treatment, including pancreatectomies and extrahepatic bile duct resections. This review presents and discusses the state of the art in the laparoscopic and robotic surgical treatment of all types of CC. An electronic search was performed to identify all studies dealing with laparoscopic or robotic surgery and cholangiocarcinoma. Laparoscopic resection in patients with intrahepatic CC (ICC) is feasible and safe. Regarding oncologic adequacy, as R0 resections, depth of margins, and long-term overall and disease-free survival, laparoscopy is comparable to open procedures for ICC. An adequate patient selection is required to obtain optimal results. Use of laparoscopy in perihilar CC (PHC) has not gained popularity. Further studies are still needed to confirm the benefit of this approach over conventional surgery for PHC. Laparoscopic pancreaticoduodenectomy for distal CC (DCC) represents one of the most advanced abdominal operations owing to the necessity of a complex dissection and reconstruction and has also had small widespread so far. Minimally invasive surgery seems feasible and safe especially for ICC. Laparoscopy for PHC is technically challenging notably for the caudate lobectomy. Not least as for the LLR, the robotic approach for DCC appears technically achievable in selected patients.

Can laparoscopic liver resection provide a favorable option for patients with large or multiple intrahepatic cholangiocarcinomas?

BACKGROUND

The role of laparoscopic liver resection (LLR) for large or multiple intrahepatic cholangiocarcinomas (ICCs) remains equivocal. The main concerns are potential risks of inadequate resection margin, tumor rupture, uncontrollable bleeding, tumor seeding, and inadequate lymph node sampling. In this study, we aimed to determine the safety, feasibility, and oncological efficacy of LLR for large (≥5 cm) or multiple (≥2) ICCs.

METHODS

Among 50 patients receiving liver resection for ICC between May 2004 and January 2016, 12 patients who had undergone LLR for large or multiple ICCs (Group A, n = 12) were compared with 18 patients who had undergone LLR for small solitary ICCs (Group B, n = 18), as well were compared with 20 patients who had undergone open liver resection for large or multiple ICCs (Group C, n = 20). Perioperative and long-term outcomes were analyzed.

RESULTS

Compared with Group B, Group A had fewer patients with T1 tumors (58.3 vs. 100%; P = 0.006) and a longer hospital stay (14 vs. 9 days; P = 0.039); operating time, blood loss, surgical margin, cases receiving lymph node dissection, conversion rates, and morbidity were comparable. There were no life-threatening complications and no mortality. No tumor rupture or dissemination occurred, nor did port-site recurrence follow surgery. After a median follow-up of 22 months, no difference was noted in 3-year overall survival (56.3 vs. 59.5%; P > 0.05) and recurrence-free survival (43.8 vs. 50%; P > 0.05) between the two groups. Similarly, perioperative and long-term outcomes were comparable between Group A and Group C.

CONCLUSION

LLR for large or multiple ICCs is technically safe, feasible, and oncologically effective in select patients. It provides a favorable option for patients seeking curative treatment. The minimally invasive nature will benefit these patients without compromising the oncological efficacy. Future larger-scale studies and well-designed randomized trials are warranted to evaluate this issue.