Minimally Invasive Surgery for Perihilar Cholangiocarcinoma: A Systematic Review of the Short- and Long-Term Results

Abstract

Surgery and postoperative systemic chemotherapy represent the standard treatment for patients with perihilar cholangiocarcinoma (PHC). Minimally Invasive Surgery (MIS) for hepatobiliary procedures has spread worldwide in the last two decades. Since resections for PHC are technically demanding, the role of MIS in this field is yet to be established. This study aimed to systematically review the existing literature on MIS for PHC, to evaluate its safety and its surgical and oncological outcomes. A systematic literature review on PubMed and SCOPUS was performed according to the PRISMA guidelines. Overall, a total of 18 studies reporting 372 MIS procedures for PHC were included in our analysis. A progressive increase in the available literature was observed over the years. A total of 310 laparoscopic and 62 robotic resections were performed. A pooled analysis showed an operative time ranging from 205.3 ± 23.9 and 840 (770–890) minutes, and intraoperative bleeding between 101.1 ± 13.6 and 1360 ± 809 mL. Minor and major morbidity rates were 43.9% and 12.7%, respectively, with a 5.6% mortality rate. R0 resections were achieved in 80.6% of patients and the number of retrieved lymph nodes ranged between 4 (3–12) and 12 (8–16). This systematic review shows that MIS for PHC is feasible, with safe postoperative and oncological outcomes. Recent data has shown encouraging results and more reports are being published. Future studies should address differences between robotic and laparoscopic approaches. Given the management and technical challenges, MIS for PHC should be performed by experienced surgeons, in high-volume centers, on selected patients.

Robotic Hepatectomy plus Biliary Reconstruction for Bismuth Type III and Type IV Hilar Cholangiocarcinoma: State of the Art and Literature Review

“…The conversion rate was 4% in total. These data are in line with another recent systematic review on all types of HC treated with minimally invasive surgery [25]. In this latter paper, which however also included easier cases (e.g., type I and II), robotic approaches had a conversion rate of 1.9%, while laparoscopy had a conversion rate of 11.6%.…”

“…Thus, very aggressive surgical treatment is generally required to increase the chances of long-term survival. Particularly for type III or type IV subgroups, detailed pre-operative planning is mandatory with liver remnant measures, because the surgical procedure, as well as the resection of the biliary confluence, consists mostly of an en-bloc major hepatectomy, with a consequent risk of post-operative hepatic disfunction [25]. The other crucial phase in this situation is the hilar one with a clear definition of all biliary ductal branches and the involved vessels, which can also be difficult to outline during open surgery.…”

Initial clinical outcomes of robotic resection for perihilar cholangiocarcinoma: Is it safe and effective?

“…The significant morbidity presented by PHC resection with literature for both laparoscopic and open approaches make preoperative management and optimization increasingly important 13 . In this study 91% of patients underwent preoperative biliary drainage before their operation.…”

“…Our results exhibit good perioperative outcomes for patients and promising early‐term oncologic outcomes. The role of minimally invasive approaches for PHC resection is growing after early limitation with conventional laparoscopy approach, making meticulous dissection and the creation of delicate bilioenteric anastomoses difficult 13 . These challenges highlighted the variance between institutions with high minimally invasive volume.…”

“…These challenges highlighted the variance between institutions with high minimally invasive volume. The adoption of the robotic platform has shown a reduction in intraoperative conversion to open, possibly due to the 3‐dimensional visualization, improved surgeon's dexterity, tremor reduction and 7‐degrees of freedom the robotic technology provides 13 . It is widely accepted that minimally invasive approaches can shorten length of stay and improve perioperative outcomes without sacrificing the oncologic goals when performed by experienced robotic hepatobiliary surgeons 14,15 .…”