The role of minimally invasive surgery in the treatment of cholangiocarcinoma

doi:10.1016/j.ejso.2017.02.012

European Journal of Surgical Oncology

Volume 43, Issue 9, September 2017, Pages 1617-1621

https://doi.org/10.1016/j.ejso.2017.02.012 Get rights and content

Abstract

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.

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.

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Cited by (44)

Research trends in cholangiocarcinoma treatments during the last 3 decades
2023, Heliyon
Over the past 30 years, numerous studies have focused on the treatment of cholangiocarcinoma (CCA), and these treatments have greatly evolved.
To better understand the research trends, we evaluated the most influential publications and attempted to identify their characteristics using bibliometric methods.
The most influential publications were identified from the Clarivate Analytics Web of Science Core Collection database. The general characteristics of included papers were identified, and the research trends were explored via the bibliometric method.
The average total number of citations for of the listed publications were 312 (range from 165 to 1922). The highest number of papers were published during period II (2001–2010, n = 50), followed by period III (2011–2020, n = 28), and period I (1991–2000, n = 22). The United States and Germany have made remarkable achievements in this field. Institutionally, Mayo Clinic and Memorial Sloan-Kettering Cancer Center were the leading institutions, with Blumgart and Zhu from the United States being the most influential authors. Close collaboration was established between the leading countries, institutions, and authors. The Annals of Surgery contributed the most to the papers with the highest total number of citations. Surgery predominated during period I (n = 14, 63.6%), with a gradual decline occurring during periods II (n = 19, 41.3%, P = 0.085) and period III (n = 3, 9.4%, P = 0.002). Contrastingly, the number of publications related to systemic therapy has increased significantly since period II and peaked in period III.
Surgery remains the most important treatment for CCA. However systemic therapy has become a research and clinical application hotspot. These findings will contribute to the translation of treatments for CCA and provide researchers with relevant research directions.
EASL-ILCA Clinical Practice Guidelines on the management of intrahepatic cholangiocarcinoma
2023, Journal of Hepatology
Intrahepatic cholangiocarcinoma (iCCA) develops inside the liver, between bile ductules and the second-order bile ducts. It is the second most frequent primary liver cancer after hepatocellular carcinoma, and its global incidence is increasing. It is associated with an alarming mortality rate owing to its silent presentation (often leading to late diagnosis), highly aggressive nature and resistance to treatment. Early diagnosis, molecular characterisation, accurate staging and personalised multidisciplinary treatments represent current challenges for researchers and physicians. Unfortunately, these challenges are beset by the high heterogeneity of iCCA at the clinical, genomic, epigenetic and molecular levels, very often precluding successful management. Nonetheless, in the last few years, progress has been made in molecular characterisation, surgical management, and targeted therapy. Recent advances together with the awareness that iCCA represents a distinct entity amongst the CCA family, led the ILCA and EASL governing boards to commission international experts to draft dedicated evidence-based guidelines for physicians involved in the diagnostic, prognostic, and therapeutic management of iCCA.
Clinical treatment of cholangiocarcinoma: an updated comprehensive review
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Citation 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].
Cholangiocarcinoma (CCA) is a heterogeneous group of neoplasms of the bile ducts and represents the second most common hepatic cancer after hepatocellular carcinoma; it is sub-classified as intrahepatic cholangiocarcinoma (iCCA) and extrahepatic cholangiocarcinoma (eCCA), the latter comprising both perihilar cholangiocarcinoma (pCCA or Klatskin tumor), and distal cholangiocarcinoma (dCCA).
The global incidence of CCA has increased worldwide in recent decades. Chronic inflammation of biliary epithelium and bile stasis represent the main risk factors shared by all CCA sub-types.
When feasible, liver resection is the treatment of choice for CCA, followed by systemic chemotherapy with capecitabine. Liver transplants represent a treatment option in patients with very early iCCA, in referral centers only. CCA diagnosis is often performed at an advanced stage when CCA is unresectable. In this setting, systemic chemotherapy with gemcitabine and cisplatin represents the first treatment option, but the prognosis remains poor.
In order to ameliorate patients’ survival, new drugs have been studied in the last few years. Target therapies are directed against different molecules, which are altered in CCA cells. These therapies have been studied as second-line therapy, alone or in combination with chemotherapy. In the same setting, the immune checkpoints inhibitors targeting programmed death 1 (PD-1), programmed death-ligand 1 (PD-L1), cytotoxic T-lymphocyte antigen-4 (CTLA-4), have been proposed, as well as cancer vaccines and adoptive cell therapy (ACT). These experimental treatments showed promising results and have been proposed as second- or third-line treatment, alone or in combination with chemotherapy or target therapies.
Minimally Invasive Approach Provides Oncological Benefit in Patients with High Risk of Very Early Recurrence (VER) After Surgery for Intrahepatic Cholangiocarcinoma (iCCA)
2024, Annals of Surgical Oncology
Biliary-enteric reconstruction in laparoscopic radical resection of hilar cholangiocarcinoma: a single-center retrospective cohort study
2023, BMC Cancer
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

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ReviewThe role of minimally invasive surgery in the treatment of cholangiocarcinoma

Abstract

Introduction

Section snippets

Method

Liver minimally invasive surgery

Staging laparoscopy

Intrahepatic cholangiocarcinoma

Perihilar Cholangiocarcinoma

Distal Cholangiocarcinoma

Robotic approach

Conclusion

Conflict of interest

Hepatology

J Hepatol

Biliary tract cancer: epidemiology, radiotherapy, and molecular profiling

Am Soc Clin Oncol Educ Book

Multimodality treatment of intrahepatic cholangiocarcinoma: a review

J Surg Oncol

Treatment outcomes and prognostic factors of intrahepatic cholangiocarcinoma

Oncol Rep

The international position on laparoscopic liver surgery: the Louisville Statement, 2008

Ann Surg

Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka

Ann Surg

Staging laparoscopy for hilar cholangiocarcinoma in 100 patients

Langenbecks Arch Surg

Role of laparoscopic ultrasound during diagnostic laparoscopy for proximal biliary cancers: a single series of 100 patients

Surg Endosc

Diagnostic accuracy of staging laparoscopy for detecting metastasized or locally advanced perihilar cholangiocarcinoma: a systematic review and meta-analysis

Surg Endosc

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

Review
The role of minimally invasive surgery in the treatment of cholangiocarcinoma