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Sposito C, Maspero M, Cucchetti A, Mazzaferro V. A snapshot on current approaches to lymphadenectomy in liver resection for intrahepatic cholangiocarcinoma: results from an international survey. Updates Surg 2024:10.1007/s13304-024-01852-0. [PMID: 38713394 DOI: 10.1007/s13304-024-01852-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 04/10/2024] [Indexed: 05/08/2024]
Abstract
The use of lymphadenectomy (LND) during resection of intrahepatic cholangiocarcinoma (ICC) is still debated, leading to differing practices in different centers and countries. The aim of this study was to assess such differences. A survey on LND for ICC was distributed to the members of the International Hepato-PancreatoBiliary Association (IHPBA) and the Italian Chapter of IHPBA (AICEP). Two-hundred thirty-four surgeons completed the survey (88% males; median age 46 years). Preoperative nodal staging was deemed mandatory/very important by 65%. Adequate LND was defined as hepatoduodenal ligament LND by 33%, LND at specific nodal stations by 28% and retrieval of > 5 nodes by 28%. The decision to perform LND was influenced by comorbidities (48%), chronic liver disease (38%) and satellitosis (32%). Most participants modify perioperative management in case of clinically positive nodes, 50% stating they would give neoadjuvant therapy. The role of LND in clinically node negative disease was adequate staging for 88%, survival benefit for 50.5% and clinical trials eligibility for 18.5%. Our survey confirms heterogeneity in the evaluation of role and extent of LND for ICC, how this relates to subjective perception of importance of LND, and need of a systematic approach in this area.
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Affiliation(s)
- Carlo Sposito
- HPB Surgery and Liver Transplantation Unit, Fondazione, IRCCS Istituto Nazionale Tumori di Milano, Via Venezian 1, 20133, Milan, Italy.
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.
| | - Marianna Maspero
- HPB Surgery and Liver Transplantation Unit, Fondazione, IRCCS Istituto Nazionale Tumori di Milano, Via Venezian 1, 20133, Milan, Italy
| | - Alessandro Cucchetti
- Department of Medical and Surgical Sciences, DIMEC, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Morgagni, Pierantoni Hospital, Forlì, Italy
| | - Vincenzo Mazzaferro
- HPB Surgery and Liver Transplantation Unit, Fondazione, IRCCS Istituto Nazionale Tumori di Milano, Via Venezian 1, 20133, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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2
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Alaimo L, Endo Y, Catalano G, Ruzzenente A, Aldrighetti L, Weiss M, Bauer TW, Alexandrescu S, Poultsides GA, Maithel SK, Marques HP, Martel G, Pulitano C, Shen F, Cauchy F, Koerkamp BG, Endo I, Kitago M, Pawlik TM. Benchmarks in Liver Resection for Intrahepatic Cholangiocarcinoma. Ann Surg Oncol 2024; 31:3043-3052. [PMID: 38214817 PMCID: PMC10997542 DOI: 10.1245/s10434-023-14880-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/21/2023] [Indexed: 01/13/2024]
Abstract
INTRODUCTION Benchmarking in surgery has been proposed as a means to compare results across institutions to establish best practices. We sought to define benchmark values for hepatectomy for intrahepatic cholangiocarcinoma (ICC) across an international population. METHODS Patients who underwent liver resection for ICC between 1990 and 2020 were identified from an international database, including 14 Eastern and Western institutions. Patients operated on at high-volume centers who had no preoperative jaundice, ASA class <3, body mass index <35 km/m2, without need for bile duct or vascular resection were chosen as the benchmark group. RESULTS Among 1193 patients who underwent curative-intent hepatectomy for ICC, 600 (50.3%) were included in the benchmark group. Among benchmark patients, median age was 58.0 years (interquartile range [IQR] 49.0-67.0), only 28 (4.7%) patients received neoadjuvant therapy, and most patients had a minor resection (n = 499, 83.2%). Benchmark values included ≥3 lymph nodes retrieved when lymphadenectomy was performed, blood loss ≤600 mL, perioperative blood transfusion rate ≤42.9%, and operative time ≤339 min. The postoperative benchmark values included TOO achievement ≥59.3%, positive resection margin ≤27.5%, 30-day readmission ≤3.6%, Clavien-Dindo III or more complications ≤14.3%, and 90-day mortality ≤4.8%, as well as hospital stay ≤14 days. CONCLUSIONS Benchmark cutoffs targeting short-term perioperative outcomes can help to facilitate comparisons across hospitals performing liver resection for ICC, assess inter-institutional variation, and identify the highest-performing centers to improve surgical and oncologic outcomes.
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Affiliation(s)
- Laura Alaimo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
- Department of Surgery, University of Verona, Verona, Italy
| | - Yutaka Endo
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | | | | | | | - Matthew Weiss
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Todd W Bauer
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | | | | | | | - Hugo P Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | | | - Carlo Pulitano
- Department of Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia
| | - Feng Shen
- Department of Surgery, Eastern Hepatobiliary Surgery Hospital, Shanghai, China
| | - François Cauchy
- Department of Hepatobiliopancreatic Surgery and Liver Transplantation, AP-HP, Beaujon Hospital, Clichy, France
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Minoru Kitago
- Department of Surgery, Keio University, Tokyo, Japan
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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3
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Andraus W, Tustumi F, Santana AC, Pinheiro RSN, Waisberg DR, Lopes LD, Arantes RM, Santos VR, de Martino RB, D'Albuquerque LAC. Liver transplantation as an alternative for the treatment of perihilar cholangiocarcinoma: A critical review. Hepatobiliary Pancreat Dis Int 2024; 23:139-145. [PMID: 38310060 DOI: 10.1016/j.hbpd.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 01/19/2024] [Indexed: 02/05/2024]
Abstract
BACKGROUND Perihilar cholangiocarcinoma (phCCC) is a dismal malignancy. There is no consensus regarding the best treatment for patients with unresectable phCCC. The present review aimed to gather the current pieces of evidence for liver transplantation and liver resection as a treatment for phCCC and to build better guidance for clinical practice. DATA SOURCES The search was conducted in PubMed, Embase, Cochrane, and LILACS. The related references were searched manually. Inclusion criteria were: reports in English or Portuguese literature that a) patients with confirmed diagnosis of phCCC; b) patients treated with a curative intent; c) patients with the outcomes of liver resection and liver transplantation. Case reports, reviews, letters, editorials, conference abstracts and papers with full-text unavailability were excluded from the analysis. RESULTS Most of the current literature is based on observational retrospective studies with low grades of evidence. Liver resection has better long-term outcomes than systemic chemotherapy or palliation therapy and liver transplantation is a good alternative for selected patients with unresectable phCCC. All candidates for resection or transplantation should be medically fit and free of intrahepatic or extrahepatic diseases. As a general rule, patients presenting with a tumor having a longitudinal size > 3 cm or extending below the cystic duct, lymph node disease, confirmed extrahepatic dissemination; intraoperatively diagnosed metastatic disease; a history of other malignancies within the last five years, and did not complete chemoradiation regimen and were medically unfit should not be considered for transplantation. Some of these criteria should be individually assessed. Liver transplantation or resection should only be considered in highly experienced hepatobiliary centers, and any decision-making must be based on a multidisciplinary evaluation. CONCLUSIONS phCCC is a complex condition with high morbidity. Surgical therapies, including hepatectomy and liver transplantation, are the best option for better long-term disease-free survival.
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Affiliation(s)
- Wellington Andraus
- Department of Gastroenterology, Transplantation Unit, Universidade de São Paulo, São Paulo, Brazil.
| | - Francisco Tustumi
- Department of Gastroenterology, Transplantation Unit, Universidade de São Paulo, São Paulo, Brazil
| | - Alexandre Chagas Santana
- Department of Gastroenterology, Transplantation Unit, Universidade de São Paulo, São Paulo, Brazil
| | | | - Daniel Reis Waisberg
- Department of Gastroenterology, Transplantation Unit, Universidade de São Paulo, São Paulo, Brazil
| | - Liliana Ducatti Lopes
- Department of Gastroenterology, Transplantation Unit, Universidade de São Paulo, São Paulo, Brazil
| | - Rubens Macedo Arantes
- Department of Gastroenterology, Transplantation Unit, Universidade de São Paulo, São Paulo, Brazil
| | - Vinicius Rocha Santos
- Department of Gastroenterology, Transplantation Unit, Universidade de São Paulo, São Paulo, Brazil
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Sucandy I, Marques HP, Lippert T, Magistri P, Coelho JS, Ross SB, Chumbinho B, Di Sandro S, DiBenedetto F. ASO Author Reflections: Clinical Outcomes of Robotic Resection for Perihilar Cholangiocarcinoma: A First Multicenter, Trans-Atlantic, Expert-Center Collaborative Study. Ann Surg Oncol 2024; 31:154-155. [PMID: 37773564 DOI: 10.1245/s10434-023-14362-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/13/2023] [Indexed: 10/01/2023]
Affiliation(s)
| | - Hugo P Marques
- Hepato-Biliary-Pancreatic and Transplantation Center, Lisbon Central Hospitals and University Center/NOVA Medical School, Lisbon, Portugal
| | - Trenton Lippert
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy
| | - Joao Santos Coelho
- Hepato-Biliary-Pancreatic and Transplantation Center, Lisbon Central Hospitals and University Center/NOVA Medical School, Lisbon, Portugal
| | | | - Beatriz Chumbinho
- Hepato-Biliary-Pancreatic and Transplantation Center, Lisbon Central Hospitals and University Center/NOVA Medical School, Lisbon, Portugal
| | - Stefano Di Sandro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy
| | - Fabrizio DiBenedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy
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5
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Lluís N, Asbun D, Wang JJ, Cao HST, Jimenez RE, Alseidi A, Asbun H. Lymph Node Dissection in Intrahepatic Cholangiocarcinoma: a Critical and Updated Review of the Literature. J Gastrointest Surg 2023; 27:3001-3013. [PMID: 37550590 DOI: 10.1007/s11605-023-05696-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/15/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Lymphatic spread of intrahepatic cholangiocarcinoma (iCCA) is common and negatively impacts survival. However, the precise role of lymph node dissection (LND) in oncologic outcomes for patients with intrahepatic cholangiocarcinoma remains to be established. METHODS Updated evidence on the preoperative diagnosis and prognostic value of lymph node metastasis is reviewed, as well as the potential benefit of LND in patients with iCCA. RESULTS The ability to accurately determine nodal status for iCCA with current imaging modalities is equivocal. LND has prognostic value for both survival and disease recurrence. However, execution rates of LND are highly varied in the literature, ranging from 26.9 to 100%. At least 6 lymph nodes should be examined from nodal stations of the hepatoduodenal ligament and hepatic artery as well as based on the location of the primary tumor. Neoadjuvant therapies may be beneficial if lymph node metastases at diagnosis are suspected. Surgeons performing a minimally invasive approach should focus on increasing LND rates and harvesting ≥ 6 lymph nodes. Lymph node negativity is required in patients with iCCA being considered for liver transplantation under investigational protocols. CONCLUSION Despite an upward trend in the LND rate, the reality is that only 10% of patients with iCCA receive an adequate LND. This review underscores the importance of routinely increasing the rate of adequate LND in these patients in order to achieve accurate staging, appropriately select patients for adjuvant therapy, and improve the prognosis of clinical outcomes. While prospective data is lacking, the therapeutic impact of LND remains unknown.
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Affiliation(s)
- Núria Lluís
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, 8900 N Kendall Dr, Miami, FL, 33176, USA.
| | - Domenech Asbun
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, 8900 N Kendall Dr, Miami, FL, 33176, USA
| | - Jaeyun Jane Wang
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Hop S Tran Cao
- Department of Surgical Oncology, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Ramon E Jimenez
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, 8900 N Kendall Dr, Miami, FL, 33176, USA
| | - Adnan Alseidi
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Horacio Asbun
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, 8900 N Kendall Dr, Miami, FL, 33176, USA
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6
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Hu YF, Hu HJ, Ma WJ, Jin YW, Li FY. Laparoscopic versus open liver resection for intrahepatic cholangiocarcinoma: a systematic review of propensity score-matched studies. Updates Surg 2023; 75:2049-2061. [PMID: 37919559 PMCID: PMC10710389 DOI: 10.1007/s13304-023-01648-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 09/21/2023] [Indexed: 11/04/2023]
Abstract
Outcomes of laparoscopic liver resection (LLR) versus open LR (OLR) for intrahepatic cholangiocarcinoma (ICCA) are heterogeneous. We aimed to compare LLR and OLR for ICCA based on propensity-score-matched (PSM) studies. Two reviewers independently searched the online databases (PubMed, Embase, and Cochrane Library) for PSM studies that compared LLR and OLR for ICCA. The Ottawa-Newcastle Quality Assessment Scale with a cutoff of ≥ 7 was used to define higher-quality literature. Only 'high-quality' PSM analyses of the English language that met all our inclusion criteria were considered. A total of ten PSM trials were included in the analyses. Compared with OLR, although the lymph node dissection (LND) (RR = 0.67) and major hepatectomy rates were lower in the LLR group (RR = 0.87), higher R0 resections (RR = 1.05) and lower major complications (Clavien-Dindo grade ≥ III) (RR = 0.72) were also observed in the LLR group. In addition, patients in the LLR group showed less estimated blood loss (MD = - 185.52 ml) and shorter hospital stays as well (MD = - 2.75 days). Further analysis found the overall survival (OS) (HR = 0.91), disease-free survival (DFS) (HR = 0.95), and recurrence-free survival (HR = 0.80) for patients with ICCA after LLR were all comparable to those of OLR. LLR for selected ICCA patients may be technically safe and feasible, providing short-term benefits and achieving oncological efficacy without compromising the long-term survival of the patients.
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Affiliation(s)
- Ya-Fei Hu
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan, China
| | - Hai-Jie Hu
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan, China
| | - Wen-Jie Ma
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan, China
| | - Yan-Wen Jin
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan, China
| | - Fu-Yu Li
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan, China.
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7
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Ma D, Wang W, Wang J, Zhang T, Jiang Z, Du G, Yang J, Zhang X, Qin G, Jin B. Laparoscopic versus open surgery for hilar cholangiocarcinoma: a retrospective cohort study on short-term and long-term outcomes. Surg Endosc 2022; 36:3721-3731. [PMID: 34398281 DOI: 10.1007/s00464-021-08686-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 08/07/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Laparoscopic surgery (LS) for hilar cholangiocarcinoma (HCCa) remains under development, and its feasibility and safety remain controversial. This study therefore evaluated the outcomes of this technique and compared them to those of open surgery (OS). METHODS In total, 149 patients underwent surgical resection for HCCa at our center between February 2017 and September 2020. After screening and propensity score matching, 47 OS group patients and 20 LS group patients remained, and their baseline characteristics, pathologic findings, surgical outcomes, and long-term outcomes were compared. RESULT The baseline characteristics and pathologic findings were comparable between the two groups. The mean incision length was longer in the OS group than in the LS group (21.0 cm vs. 13.2 cm, P < 0.001). No significant differences were observed in the other surgical outcomes between the two groups. Regarding long-term outcomes, the overall survival rate and disease-free survival rate of the OS group were significantly higher than those of the LS group (P = 0.0057, P = 0.043). However, the two groups had significantly different follow-up times (19.2 months vs. 14.7 months, P = 0.041). CONCLUSION LS for HCCa is technically achievable, and our study revealed that it is equivalent to OS in terms of short-term outcomes but was poorer in terms of long-term outcomes.
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Affiliation(s)
- Delin Ma
- Department of Surgery, School of Medicine, Cheeloo College of Medicine, Shandong University, 44 Wenhuaxi Road, Jinan, 250012, Shandong, China.,Department of Organ Transplantation, Qilu Hospital, Cheeloo College of Medicine, Shandong University, 107 Wenhuaxi Road, Jinan, 250012, Shandong, China
| | - Wei Wang
- Department of Surgery, School of Medicine, Cheeloo College of Medicine, Shandong University, 44 Wenhuaxi Road, Jinan, 250012, Shandong, China
| | - Jianlei Wang
- Department of Organ Transplantation, Qilu Hospital, Cheeloo College of Medicine, Shandong University, 107 Wenhuaxi Road, Jinan, 250012, Shandong, China
| | - Tingxiao Zhang
- Department of Organ Transplantation, Qilu Hospital, Cheeloo College of Medicine, Shandong University, 107 Wenhuaxi Road, Jinan, 250012, Shandong, China
| | - Zhaochen Jiang
- Department of Organ Transplantation, Qilu Hospital, Cheeloo College of Medicine, Shandong University, 107 Wenhuaxi Road, Jinan, 250012, Shandong, China
| | - Gang Du
- Department of Organ Transplantation, Qilu Hospital, Cheeloo College of Medicine, Shandong University, 107 Wenhuaxi Road, Jinan, 250012, Shandong, China
| | - Jinhuan Yang
- Department of Organ Transplantation, Qilu Hospital, Cheeloo College of Medicine, Shandong University, 107 Wenhuaxi Road, Jinan, 250012, Shandong, China
| | - Xiqing Zhang
- School of Public Health, Cheeloo College of Medicine, Shandong University, 44 Wenhuaxi Road, Jinan, 250012, Shandong, China
| | - Guanjun Qin
- Department of Hepatobiliary Surgery, Xuchang Central Hospital Affiliated to Henan University of Science and Technology, Xuchang, 461000, Henan, China
| | - Bin Jin
- Department of Organ Transplantation, Qilu Hospital, Cheeloo College of Medicine, Shandong University, 107 Wenhuaxi Road, Jinan, 250012, Shandong, China.
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Spiegelberg J, Iken T, Diener MK, Fichtner-Feigl S. Robotic-Assisted Surgery for Primary Hepatobiliary Tumors-Possibilities and Limitations. Cancers (Basel) 2022; 14:cancers14020265. [PMID: 35053429 PMCID: PMC8773643 DOI: 10.3390/cancers14020265] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/26/2021] [Accepted: 01/05/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Primary liver malignancies are some of the most common and fatal tumors today. Robotic-assisted liver surgery is becoming increasingly interesting for both patients and surgeons alike. Up to date, prospective comparative studies around the topic are scarce. This leads us to an ever existing controversy about the efficacy, safety, and economic benefits of robotic surgery as an extension of traditional minimally invasive surgery over open liver surgery. However, there is evidence that robotic-assisted surgery is, after passing the learning curve, equivalent in terms of feasibility and safety, and in some cases superior to traditional laparoscopic hepatic resection. With this work, we want to provide an overview of the latest and most significant reviews and meta-analyses focusing on robotic hepatectomy in primary liver malignancies. We outline the technical aspects of robotic-assisted surgery and place them into the context of technical, surgical, and oncological outcomes compared with laparoscopic and open resection. When chosen per case individually, any hepatic resection can be performed robotically to overcome limitations of laparoscopic surgery by an experienced team. In this paper, we propose that prospective studies are needed to prove efficacy for robotic-assisted resection in liver malignancy. Abstract Hepatocellular and cholangiocellular carcinoma are fatal primary hepatic tumors demanding extensive liver resection. Liver surgery is technically challenging due to the complex liver anatomy, with an intensive and variant vascular and biliary system. Therefore, major hepatectomies in particular are often performed by open resection and minor hepatectomies are often performed minimally invasively. More centers have adopted robotic-assisted surgery, intending to improve the laparoscopic surgical limits, as it offers some technical benefits such as seven degrees of freedom and 3D visualization. The da Vinci® Surgical System has dominated the surgical robot market since 2000 and has shown surgical feasibility, but there is still much controversy about its economic benefits and real benefits for the patient over the gold standard. The currently available retrospective case studies are difficult to compare, and larger, prospective studies and randomized trials are still urgently missing. Therefore, here we summarize the technical, surgical, and economic outcomes of robotic versus open and laparoscopic hepatectomies for primary liver tumors found in the latest literature reviews and meta-analyses. We conclude that complex robotic liver resections (RLR) are safe and feasible after the steep learning curve of the surgical team has plateaued. The financial burden is lower in high volume centers and is expected to decrease soon as new surgical systems will enter the market.
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Manzia TM, Parente A, Lenci I, Sensi B, Milana M, Gazia C, Signorello A, Angelico R, Grassi G, Tisone G, Baiocchi L. Moving forward in the treatment of cholangiocarcinoma. World J Gastrointest Oncol 2021; 13:1939-1955. [PMID: 35070034 PMCID: PMC8713313 DOI: 10.4251/wjgo.v13.i12.1939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/14/2021] [Accepted: 10/14/2021] [Indexed: 02/06/2023] Open
Abstract
Despite being the second most frequent primary liver tumor in humans, early diagnosis and treatment of cholangiocarcinoma (CCA) are still unsatisfactory. In fact, survival after 5 years is expected in less than one fourth of patients diagnosed with this disease. Rare incidence, late appearance of symptoms and heterogeneous biology are all factors contributing to our limited knowledge of this cancer and determining its poor prognosis in the clinical setting. Several efforts have been made in the last decades in order to achieve an improved classification/understanding with regard to the diverse CCA forms. Location within the biliary tree has helped to distinguish between intrahepatic, perihilar and distal CCA types. Sequence analysis contributed to identifying several characteristic genetic aberrations in CCA that may also serve as possible targets for therapy. Novel findings are expected to significantly improve the management of this malignancy in the near future. In this changing scenario our review focuses on the current and future strategies for CCA treatment. Both systemic and surgical treatments are discussed in detail. The results of the main studies in this field are reported, together with the ongoing trials. The current findings suggest that an integrated multidisciplinary approach to this malignancy would be helpful to improve its outcome.
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Affiliation(s)
- Tommaso M Manzia
- Hepato-Pancreato-Biliary and Transplant, Department of Surgery, University of Rome Tor Vergata, Rome 00133, Italy
| | - Alessandro Parente
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom
| | - Ilaria Lenci
- Hepatology Unit, University of Tor Vergata, Rome 00133, Italy
| | - Bruno Sensi
- Hepato-Pancreato-Biliary and Transplant, Department of Surgery, University of Rome Tor Vergata, Rome 00133, Italy
| | - Martina Milana
- Hepatology Unit, University of Tor Vergata, Rome 00133, Italy
| | - Carlo Gazia
- Hepato-Pancreato-Biliary and Transplant, Department of Surgery, University of Rome Tor Vergata, Rome 00133, Italy
| | | | - Roberta Angelico
- Hepato-Pancreato-Biliary and Transplant, Department of Surgery, University of Rome Tor Vergata, Rome 00133, Italy
| | - Giuseppe Grassi
- Hepatology Unit, University of Tor Vergata, Rome 00133, Italy
| | - Giuseppe Tisone
- Hepato-Pancreato-Biliary and Transplant, Department of Surgery, University of Rome Tor Vergata, Rome 00133, Italy
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10
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Bekki Y, Von Ahrens D, Takahashi H, Schwartz M, Gunasekaran G. Recurrent Intrahepatic Cholangiocarcinoma - Review. Front Oncol 2021; 11:776863. [PMID: 34746017 PMCID: PMC8567135 DOI: 10.3389/fonc.2021.776863] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/01/2021] [Indexed: 12/15/2022] Open
Abstract
Intrahepatic cholangiocarcinoma (ICC) is the second-most common primary liver malignancy after hepatocellular carcinoma. While surgical resection with negative margin is the only curative treatment, ICC has very high rate of recurrence, up to 60-70% after curative resection. We reviewed the current data available on risk factors for ICC recurrence, recurrence pattern (location and timing), treatment options, and future directions. The risk factors for recurrence include elevated preoperative CA19-9, presence of liver cirrhosis, nodal metastasis, positive margins, and vascular invasion. Understanding different recurrence patterns, timing course, and risk factors for early recurrence is important to tailor postoperative surveillance and select treatment strategies including systemic or locoregional therapy. Re-resection can be considered for a selected patient population at experienced centers, and can yield long-term survival. ICC remains a dismal disease given the high likelihood of recurrence. Advances in our understanding of the genomic landscape of ICC are beginning to identify targetable alterations in ICC in subsets of patients that allow for personalized treatment.
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Affiliation(s)
- Yuki Bekki
- Division of Liver Surgery, Recanati/Miller Transplantation Institute, The Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Dagny Von Ahrens
- Division of Liver Surgery, Recanati/Miller Transplantation Institute, The Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Hideo Takahashi
- Department of Surgery, Mount Sinai South Nassau, Oceanside, NY, United States
| | - Myron Schwartz
- Division of Liver Surgery, Recanati/Miller Transplantation Institute, The Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Ganesh Gunasekaran
- Division of Liver Surgery, Recanati/Miller Transplantation Institute, The Icahn School of Medicine at Mount Sinai, New York, NY, United States.,Department of Surgery, Mount Sinai South Nassau, Oceanside, NY, United States
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11
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Abstract
OPINION STATEMENT Biliary malignancies, although rare, can be some of the most challenging to manage surgically. Intrahepatic cholangiocarcinomas are resectable if there is no evidence of metastatic disease. These tumors are managed with anatomic resection and portal lymphadenectomy when centrally located or multiple in a single lobe. Non-anatomic resection can be performed for solitary peripheral tumors with minimally invasive techniques. It is not our practice to routinely employ neoadjuvant chemotherapy prior to resection of these tumors. Hepatic arterial infusion chemotherapy is utilized at our institution in highly selected patients in the context of an ongoing clinical trial for unresectable tumors. Hilar cholangiocarcinomas, when resectable (i.e., ipsilateral arterial involvement or lack of vascular involvement), are managed with right or left (extended) hepatectomy, caudate resection, and portal lymphadenectomy. Distal cholangiocarcinomas are managed with pancreaticoduodenectomy. Neoadjuvant chemotherapy is not routinely used in our treatment algorithm of extrahepatic cholangiocarcinomas. Nodal involvement and positive margin (R1) resection necessitates adjuvant chemotherapy. Finally, gallbladder carcinoma is managed with radical cholecystectomy, anatomic segment IVb/V resection, and portal lymphadenectomy. Adjuvant chemotherapy is employed routinely amongst patients with T2 or higher tumors and those with positive lymph nodes.
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Affiliation(s)
- Kimberly Washington
- Division of Surgical Oncology, Knight Cancer Institute, Oregon Health & Science University, 3181 S.W. Sam Jackson, Portland, OR, 97239, USA
| | - Flavio Rocha
- Division of Surgical Oncology, Knight Cancer Institute, Oregon Health & Science University, 3181 S.W. Sam Jackson, Portland, OR, 97239, USA.
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12
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Panayotova G, Guerra J, Guarrera JV, Lunsford KE. The Role of Surgical Resection and Liver Transplantation for the Treatment of Intrahepatic Cholangiocarcinoma. J Clin Med 2021; 10:2428. [PMID: 34070772 PMCID: PMC8199311 DOI: 10.3390/jcm10112428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 05/28/2021] [Indexed: 12/17/2022] Open
Abstract
Intrahepatic cholangiocarcinoma (iCCA) is a rare and complex malignancy of the biliary epithelium. Due to its silent presentation, patients are frequently diagnosed late in their disease course, resulting in poor overall survival. Advances in molecular profiling and targeted therapies have improved medical management, but long-term survival is rarely seen with medical therapy alone. Surgical resection offers a survival advantage, but negative oncologic margins are difficult to achieve, recurrence rates are high, and the need for adequate future liver remnant limits the extent of resection. Advances in neoadjuvant and adjuvant treatments have broadened patient treatment options, and these agents are undergoing active investigation, especially in the setting of advanced, initially unresectable disease. For those who are not able to undergo resection, liver transplantation is emerging as a potential curative therapy in certain cases. Patient selection, favorable tumor biology, and a protocolized, multidisciplinary approach are ultimately necessary for best patient outcomes. This review will discuss the current surgical management of locally advanced, liver-limited intrahepatic cholangiocarcinoma as well as the role of liver transplantation for select patients with background liver disease.
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Affiliation(s)
| | | | | | - Keri E. Lunsford
- Rutgers New Jersey Medical School, Department of Surgery, Division of Transplant and HPB Surgery, Newark, NJ 07103, USA; (G.P.); (J.G.); (J.V.G.)
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13
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Cillo U, D'Amico FE, Furlanetto A, Perin L, Gringeri E. Robotic hepatectomy and biliary reconstruction for perihilar cholangiocarcinoma: a pioneer western case series. Updates Surg 2021; 73:999-1006. [PMID: 33861401 PMCID: PMC8184707 DOI: 10.1007/s13304-021-01041-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 03/22/2021] [Indexed: 12/24/2022]
Abstract
Open surgery is the standard of care for perihilar cholangiocarcinoma (pCCA). With the aim of oncologic radicality, it requires a complex major hepatectomy with biliary reconstruction. The postoperative course is consequently often complicated, with severe morbidity and mortality rates of up to 27.5–54% and 18%, respectively. Robotic liver surgery is emerging as a safe, minimally-invasive technique with huge potential for pCCA management. After the first case described by Giulianotti in 2010, here we present the first western series of robot-assisted liver resections with biliary reconstruction for pCCA with the aim to preliminarily assess the feasibility and repeatability of the procedure. At our high-volume teaching hospital center dedicated to HPB surgery, 128 pCCA patients have been surgically treated in the last 15 years whereas more than 800 laparoscopic liver resections have been performed. Since the Da Vinci Xi Robotic platform was introduced in late 2018, 6 major robotic liver resections with biliary reconstruction have been performed, 4 of which were for pCCA. All 4 cases involved a left hepatectomy with caudate lobectomy. The median operating time was 840 min, with a median blood loss of 700 ml. One case was converted to open surgery during the reconstruction due to a short mesentery preventing the hepatico-jejunostomy. None of the patients experienced major complications, while minor complications occurred in 3 out of 4 cases. One biliary leak was managed conservatively. The median postoperative stay was 9 days. Negative biliary margins were achieved in 3 of the 4 cases. An included video clip shows the most relevant technical details. This preliminary series demonstrates that robot-assisted liver resection for pCCA is feasible. We speculate that the da Vinci platform has a relevant potential in pCCA surgery with particular reference to the multi-duct biliary reconstruction. Further studies are needed to better clarify the role of this high-cost technology in the minimally-invasive treatment of pCCA.
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Affiliation(s)
- Umberto Cillo
- Hepatobiliary Surgery and Liver Transplantation Unit, Padua University Hospital, 2° Piano Policlinico, Via Giustiniani 2, 35128, Padua, Italy.
| | - Francesco Enrico D'Amico
- Hepatobiliary Surgery and Liver Transplantation Unit, Padua University Hospital, 2° Piano Policlinico, Via Giustiniani 2, 35128, Padua, Italy
| | - Alessandro Furlanetto
- Hepatobiliary Surgery and Liver Transplantation Unit, Padua University Hospital, 2° Piano Policlinico, Via Giustiniani 2, 35128, Padua, Italy
| | - Luca Perin
- Hepatobiliary Surgery and Liver Transplantation Unit, Padua University Hospital, 2° Piano Policlinico, Via Giustiniani 2, 35128, Padua, Italy
| | - Enrico Gringeri
- Hepatobiliary Surgery and Liver Transplantation Unit, Padua University Hospital, 2° Piano Policlinico, Via Giustiniani 2, 35128, Padua, Italy
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14
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Coletta D, Levi Sandri GB, Giuliani G, Guerra F. Robot-assisted versus conventional laparoscopic major hepatectomies: Systematic review with meta-analysis. Int J Med Robot 2021; 17:e2218. [PMID: 34196090 DOI: 10.1002/rcs.2218] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 12/07/2020] [Accepted: 12/23/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Major hepatectomy is still regarded as a technically demanding procedure for which minimally invasive surgery remains limited to selected cases in experienced centres and robotic platforms may provide some advantages over conventional laparoscopy in this setting. We aimed to combine and meta-analyse the available literature upon this topic. METHODS The PubMed, MEDLINE and Web of Science databases were appraised to find all available studies comparing robotic and laparoscopic major hepatectomies. According to a pre-established pattern preoperative settings, operative and postoperative outcomes were assessed. The meta-analysis was performed by using the Revman 5.3 software. RESULTS A total of 485 patients from eight studies were included in the analysis. Robotic major hepatectomies showed a significantly lower conversion rate and estimated blood loss as compared to laparoscopic ones. Laparoscopic major hepatectomies patients experienced significant shorter postoperative hospitalisation. CONCLUSIONS Robotic surgery appears as competent as conventional laparoscopy to perform major hepatectomies, with possible advantages on conversion rate and perioperative blood loss, despite slightly prolonged postoperative hospitalisation.
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Affiliation(s)
- Diego Coletta
- Hepatopancreatobiliary Surgery, IRCCS Regina Elena National Cancer Institute, Rome, Italy.,Emergency Department-Emergency and Trauma Surgery Unit, Department of General Surgery, Umberto I University Hospital, Sapienza University of Rome, Rome, Italy
| | | | - Giuseppe Giuliani
- Division of General and Minimally Invasive Surgery, Misericordia Hospital, Grosseto, Italy
| | - Francesco Guerra
- Department of General Surgery, Ospedali Riuniti Marche Nord, Pesaro, Italy
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15
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Beal EW, Cloyd JM, Pawlik TM. Surgical Treatment of Intrahepatic Cholangiocarcinoma: Current and Emerging Principles. J Clin Med 2020; 10:E104. [PMID: 33396821 PMCID: PMC7796337 DOI: 10.3390/jcm10010104] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 12/22/2020] [Accepted: 12/28/2020] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
| | | | - Timothy M. Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH 43201, USA; (E.W.B.); (J.M.C.)
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16
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Cloyd JM, Ejaz A, Pawlik TM. The Landmark Series: Intrahepatic Cholangiocarcinoma. Ann Surg Oncol 2020; 27:2859-2865. [PMID: 32419038 DOI: 10.1245/s10434-020-08621-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Intrahepatic cholangiocarcinoma (ICC) is an aggressive biliary tract cancer (BTC) with distinct anatomic, molecular, and clinical characteristics that distinguishes it from other BTCs. METHODS In this landmark series review, we highlight the critical studies that have defined the surgical management of ICC, as well as several randomized controlled trials that have investigated adjuvant therapy strategies. RESULTS Surgical resection is the mainstay of treatment and should involve margin-negative resection with regional lymphadenectomy. Several recently completed and ongoing randomized controlled trials are defining the indications for adjuvant therapy among patients with resected ICC. CONCLUSIONS In the near future, improved understanding of the molecular features of ICC should lead to newer targeted therapies as well as a more personalized approach to systemic therapy.
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Affiliation(s)
- Jordan M Cloyd
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University, Columbus, OH, USA. .,Department of Surgery, Oncology, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Health Services Management and Policy, The Ohio State University, Wexner Medical Center, Columbus, OH, USA.
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17
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Machado MA, Mattos BV, Lobo Filho MM, Makdissi F. Robotic Resection of Hilar Cholangiocarcinoma. Ann Surg Oncol 2020; 27:4166-4170. [PMID: 32363511 DOI: 10.1245/s10434-020-08514-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hilar cholangiocarcinoma is the most common malignant neoplasm of the biliary tract. Surgical resection is the only curative modality of treatment. The aim of this video is to present a robotic left hepatectomy extended to caudate lobe, combined with bile duct resection, lymphadenectomy, and Roux-en-Y biliary reconstruction. METHODS A 76-year-old female presented with progressive jaundice due to hilar cholangiocarcinoma. She underwent chemoradiation and after 5 months of treatment was referred for second opinion; imaging reevaluation showed objective response and no arterial invasion. Multidisciplinary team decided for radical treatment, which consisted in robotic left hepatectomy, caudate lobe resection, resection of bile duct, lymphadenectomy, and hepaticojejunostomy. RESULTS Operative time was 8 h. Estimated blood loss was 740 mL (received 2 U). The patient's recovery was complicated by drainage clogging resulting in fever and perihepatic fluid collection, successfully treated by change of drainage. Pathology confirmed cholangiocarcinoma with free surgical margins (T1aN0). The patient is well, with no signs of disease 5 months after the procedure. CONCLUSIONS Robotic resection of hilar cholangiocarcinoma is feasible and safe. The robotic approach has some technical advantages over laparoscopic approach. This video may help oncological surgeons to perform this complex procedure.
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Affiliation(s)
- Marcel Autran Machado
- Department of Surgery, University of São Paulo, São Paulo, Brazil. .,Nove de Julho Hospital, São Paulo, Brazil.
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18
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Marino MV, Pellino G, Ahmad A. The robotic-assisted approach for left-side predominance hilar cholangiocarcinoma: a video technique. Updates Surg 2020; 72:911-912. [PMID: 32333323 DOI: 10.1007/s13304-020-00777-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 04/16/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Marco Vito Marino
- General Surgery Department, Hospital Universitario Marques de Valdecilla, Santander, Cantabria, Spain. .,Emergency and General Surgery Department, Azienda Ospedaliera, Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy.
| | - Gianluca Pellino
- General Surgery Department, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy.,Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Ali Ahmad
- Surgical Oncology Department, University of Kansas, School of Medicine-Wichita, Kansas, USA
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