Laparoscopic versus open liver resections for intrahepatic cholangiocarcinoma and gallbladder cancer: the Mayo clinic experience

A single institution's experience with robotic resections of biliary tract cancers: an analysis of the short-term outcomes and long-term survival

INTRODUCTION

Perihilar cholangiocarcinoma, intrahepatic cholangiocarcinoma (IHCC), and gall bladder cancer are difficult malignancies to treat and are characterized by a tendency for local recurrence and a generally unfavorable prognosis. Surgical resection offers the only potential cure, conventionally performed via the open approach. Although minimally invasive approaches show promise, data remain limited.

METHODS

With the institutional review board's approval, we prospectively followed 100 patients between 2013 and 2023 who underwent robotic surgical resection for perihilar, IHCC, and gallbladder cholangiocarcinoma. Data are presented as median (mean ± SD). Significance was accepted at P ≤ .05.

RESULTS

The median patient age was 70 years, and the median operative duration was 333 min, with an estimated blood loss of 200 mL. Importantly, no unplanned conversions occurred, and only 1 intraoperative complication occurred within the IHCC cohort. The median length of stay was 4 days. There were a total of 19 postoperative complications and 19 readmissions within 30 days. Additionally, there were 3 in-hospital mortalities and 5 90-day mortalities. R0 resection was achieved in 87% of patients and R1 resection in 13%. At a median follow-up of 36 months, 62% of patients demonstrated disease-free survival, whereas 6% continued to live with the disease, and 32% did not survive.

CONCLUSION

Our experience demonstrates the feasibility and safety of robotic resection for these complex malignancies, yielding promising short-term outcomes. Further investigation is required to ascertain the long-term oncologic outcomes.

Current Status of Laparoscopic Liver Resection

The evolution of laparoscopic liver surgery, originating in the 1990s, has been marked by significant advancements and milestones, overcoming initial technical hurdles and gaining widespread acceptance within the surgical community as a precise and safe alternative to open procedures. Along this journey, numerous challenges emerged, leading to the accumulation of evidence and the development of guidelines aimed at assisting surgeons in determining the safety, suitability, and complexity of laparoscopic liver resection. This chapter provides a thorough examination of key aspects of laparoscopic liver resection, including difficulty scoring systems, criteria for patient selection, technical considerations, outcomes across different types of liver lesions, and the innovative solutions developed to address challenges, thus offering a comprehensive overview of laparoscopic liver resection, and highlighting its evolving significance in modern hepatobiliary surgery.

Minimally Invasive Approach Provides Oncological Benefit in Patients with High Risk of Very Early Recurrence (VER) After Surgery for Intrahepatic Cholangiocarcinoma (iCCA)

BACKGROUND

Surgery for intrahepatic cholangiocarcinoma (iCCA) is jeopardized by significant risk of early recurrence (≤ 6 months). The aim of the present study is to analyze the oncological benefit provided by laparoscopic over open approach for iCCA in patients with high risk of very early recurrence (VER).

MATERIALS AND METHODS

A total of 532 liver resections (LR) were performed for iCCA [265 by minimally invasive surgery (MIS) and 267 with open approach, matched through a 1:1 propensity score] and stratified using the postoperative prediction model of VER. Outcomes were compared between open and laparoscopic approaches, specifically evaluating oncological benefit.

RESULTS

The percentage of patients with high risk of VER was similar (32.7% in the laparoscopic group and 35.3% in the open group, pNS). The number of retrieved nodes as well as the rate and depth of negative resection margins were comparable between laparoscopic and open. The surgery-adjuvant treatment interval was shorter in laparoscopic patients in the overall series, as well in the subgroup of high risk of VER. The rate of patients starting adjuvant treatments within 2 months from surgery was higher in laparoscopic group compared with open group. In VER high-risk group both disease-free survival (DFS) and overall survival (OS) were significantly improved in MIS compared with open group (p = 0.032 and p = 0.026, respectively).

CONCLUSIONS

In patients with high risk of VER, laparoscopy translates into an advantage in terms of recurrence-free survival, likely related to lower biological impact of surgery, together with a shorter interval between surgery and start of adjuvant treatments, even allowing for a higher number of patients to start adjuvant therapies within 2 months from resection.

New Insights into Surgical Management of Intrahepatic Cholangiocarcinoma in the Era of “Transplant Oncology”

Intrahepatic cholangiocarcinoma (iCCA) represents the second most frequent type of primary liver neoplasm. The diagnosis and treatment of patients with iCCA involves many challenges. To date, surgical resection with negative margins is the main curative option, achieving an acceptable long-term survival. Despite enabling a considerable improvement in the outcome, iCCA recurrence after surgery is still common. Tumor extension and the histological subtype, as well as vascular and lymph node involvements, are key factors used to define the prognosis. In this narrative review, we aimed to discuss the potential benefits of using different surgical strategies in the field of iCCA, including vascular resection, the mini-invasive approach, liver transplantation, the mechanism used to enable future liver remnant augmentation, and lymph node dissection. We also discussed the new protocols developed in the field of systemic treatment, including immunotherapy and molecular targeted therapy. Recent advancements in the diagnosis, surgical treatment, and understanding of tumor biology have changed the landscape in terms of treatment options. Creating a multidisciplinary tumor board is essential to achieving the best patient outcomes. Further investigational trials are required with the intent of tailoring the treatments and establishing the right patient population who would benefit from the use of new therapeutics algorithms.