ReviewThe role of minimally invasive surgery in the treatment of cholangiocarcinoma
Introduction
Cholangiocarcinoma (CC) is the second-most common type of primary liver cancer after hepatocellular carcinoma. The incidence of CC is between 0,35 and 2 per 100,000 population annually. Nonetheless, the incidence of intrahepatic cholangiocarcinoma (ICC) in the Western world has increased more than 165% in the past 35 years, from 0.32 per 100,000 population to 0.85 per 100,000 population, independent from potentially confounding factors such as improved microscopic detection and classification.1, 2, 3
Surgical resection is considered as the only curative treatment for CC. However only a minority of patients meet the criteria for complete resection on presentation.4, 5
Since the first reported laparoscopic hepatectomy in 1993, minimally invasive surgical techniques in liver surgery have continuously developed. Laparoscopic liver resection (LLR) is now accepted worldwide thank to the excellent results achieved.
This review presents and discusses the state of the art in the laparoscopic and robotic surgical treatment of CC.
Section snippets
Method
An electronic search was performed to identify all studies dealing with laparoscopic or robotic surgery and cholangiocarcinoma. The PubMed/MEDLINE database on May 2016 was searched. The search strategy was (“laparoscopic” OR “robotic” OR “minimally invasive”) AND (“cholangiocarcinoma”). All cases reported were resumed in Table 1.
Liver minimally invasive surgery
The first international consensus conference on LLR was held in 2008 in Louisville (KY, US). The consensus of experts concluded that the best indications for laparoscopic approaches were for solitary lesions less than 5 cm in diameter, located in the anterior segments. Nonetheless, it was recommended that adequate margins were obtained by keeping a sufficient distance from the nodule during transection; and, that LLR was applied far from the hepatic hilum and the vena cava.6
The second
Staging laparoscopy
Despite modern imaging techniques, the accuracy of preoperative radiological staging may still be poor in CC, and a number of patients are found to have unresectable locally advanced tumors or occult metastases at surgical exploration. The use of staging laparoscopy (which aims at ruling out contraindication for resection) for Perihilar Cholangiocarcinoma (PHC) saved 45% patients from an unnecessary laparotomy as described by Barlow et al.8 By associating staging laparoscopy with intraoperative
Intrahepatic cholangiocarcinoma
When ICCs require major resections (e.g. large lesions; centrally located), the laparoscopic approach may be extremely challenging, and major expertise in liver and laparoscopic technique is required. Abu Hilal et al. described two cases of laparoscopic left hepatectomy and caudate lobe resection for ICC and suggest that laparoscopic approach may be feasible, safe, and oncologically efficacious when performed within a high-volume liver center with expertise in laparoscopic liver surgery.12
Lee
Perihilar Cholangiocarcinoma
Whereas radical tumor excision is technically challenging, this approach represents the only opportunity for the patient to be cured.17
Perihilar Bismuth-Corlette type I tumors can be treated radically by a combination of cholecystectomy, extrahepatic bile duct resection, lymphadenectomy, and bilioenteric anastomosis (usually a Roux-en-Y hepaticojejunostomy). In contrast, type II, IIIA, or IIIB perihilar tumors will often require in addition to the above, a more or less extended right or left
Distal Cholangiocarcinoma
Laparoscopic pancreaticoduodenectomy represents one of the most advanced abdominal operations owing to the necessity of a complex dissection and reconstruction. The experience with laparoscopic pancreaticoduodenectomies in the treatment of DCC is essentially still at its dawn. Despite the first description by Gagner and Pomp dates back to 1994, there has not been wide acceptance of the procedure so far.24 Menon et al. described the first case in the United Kingdom of a totally laparoscopic
Robotic approach
The da Vinci Surgical System (Intuitive Surgical, Inc, Sunnyvale, CA, USA), the most widespread robotic surgical system, is now being used for even the most complex minimally invasive surgeries. Many studies demonstrated that robotic LR is feasible and a safe procedure even for major resection for hepatocellular carcinoma.28
However, the literature search for the treatment of CC with the robotic system has returned only a few articles, namely a) an experience of palliative surgery in a case of
Conclusion
Minimally invasive surgery seems feasible and safe especially for ICC. Laparoscopy for PHC is technically challenging notably due to the need of caudate lobectomy and complex bilioenteric reconstructions and this has limited its application. Similarly, laparoscopic pancreaticoduodenectomies have been reported only episodically for DCC.
The use of robotics may turn useful in promoting the application of a minimally invasive approach in major procedures in the treatment of CC. Robotic surgery has
Conflict of interest
Authors have no conflict of interest.
References (32)
Increasing incidence and mortality of primary intrahepatic cholangiocarcinoma in the United States
Hepatology
(2001)- et al.
Rising incidence of intrahepatic cholangiocarcinoma in the United States: a true increase?
J Hepatol
(2004) - et al.
Biliary tract cancer: epidemiology, radiotherapy, and molecular profiling
Am Soc Clin Oncol Educ Book
(2016) - et al.
Multimodality treatment of intrahepatic cholangiocarcinoma: a review
J Surg Oncol
(2016 Jan) - et al.
Treatment outcomes and prognostic factors of intrahepatic cholangiocarcinoma
Oncol Rep
(2013) - et al.
The international position on laparoscopic liver surgery: the Louisville Statement, 2008
Ann Surg
(2009) - et al.
Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka
Ann Surg
(2015) - et al.
Staging laparoscopy for hilar cholangiocarcinoma in 100 patients
Langenbecks Arch Surg
(2013 Oct) - et al.
Role of laparoscopic ultrasound during diagnostic laparoscopy for proximal biliary cancers: a single series of 100 patients
Surg Endosc
(2016 Mar) - et al.
Diagnostic accuracy of staging laparoscopy for detecting metastasized or locally advanced perihilar cholangiocarcinoma: a systematic review and meta-analysis
Surg Endosc
(2016 Oct)
Evaluation and management of intrahepatic and extrahepatic cholangiocarcinoma
Cancer
Pure laparoscopic en bloc left hemihepatectomy and caudate lobe resection in patients with intrahepatic cholangiocarcinoma
J Laparoendosc Adv Surg Tech A
Comparison of perioperative and oncologic outcomes between open and laparoscopic liver resection for intrahepatic cholangiocarcinoma
Surg Endosc
Laparoscopic liver resection for intrahepatic cholangiocarcinoma
J Laparoendosc Adv Surg Tech A
Safety and feasibility of laparoscopic liver resection with associated lymphadenectomy for intrahepatic cholangiocarcinoma: a propensity score-based case-matched analysis from a single institution
Surg Endosc
Pure laparoscopic right hepatectomy by anterior approach with hanging maneuver for large intrahepatic cholangiocarcinoma
Surg Endosc
Cited by (44)
EASL-ILCA Clinical Practice Guidelines on the management of intrahepatic cholangiocarcinoma
2023, Journal of HepatologyClinical treatment of cholangiocarcinoma: an updated comprehensive review
2022, Annals of HepatologyCitation Excerpt :The majority of patients with iCCA have a single large tumor that requires, similarly to pCCA, an extended hemi-hepatectomy. Conversely, the results of a minimal‐invasive resection for CCA are generally disappointing [42]. In the presence of nodal involvement beyond the hepatoduodenal and gastrohepatic ligament, the benefit of surgery decreases, due to a reported high recurrence rate [43], even though controlling disease in the liver also with a no curative surgery can improve survival, as many patients risk to die of liver insufficiency [39].
Review and Application of Integrin Alpha v Beta 6 in the Diagnosis and Treatment of Cholangiocarcinoma and Pancreatic Ductal Adenocarcinoma
2023, Technology in Cancer Research and Treatment