LAPAROSCOPIC SURGERY FOR INTRAHEPATIC CHOLANGIOCARCINOMA: A PROPENSITY SCORE MATCHING ANALYSIS
Andrea Ruzzenente*1, Nadia Russolillo2, Fabio Bagante1, Simone Conci1, Roberto Lo Tesoriere2, Tommaso Campagnaro1, Serena Langella2, Alessandro Ferrero2, Alfredo Guglielmi1
1University of Verona Medical School, Verona, Italy; 2Department of General and Oncological Surgery, Mauriziano Hospital, Turin, Italy
Background: The benefit of minimally invasive surgery (MILS) for patients with intrahepatic cholangiocarcinoma (ICC) has not been completely understood. In particular, the use of MILS fhas been associated with an inadequate lymph-node staging.
Methods: Propensity-score matching (PSM) was used to balance the clinico-pathological (gender, age, institution, type of hepatectomy, tumor size, number of tumors, grade of tumor differentiation, perineural invasion, lymphadenectomy, and lymph node status) difference between ICC patients undergoing open vs. MILS to compare short- and long-term outcomes.
Results: Among 231 patients who underwent surgery for ICC, 33 (14%) underwent MILS surgery while 198 (86%) underwent open surgery. Median age was 67 years and 55% (n=119) of patients was male. While 71% (n=154) of patients had a single ICC, 29% (n=62) of patients had a multifocal disease. The median tumor size was 5.5 cm. Lymphadenectomy was performed in 88 % (n=205), 57% (n=123) and 31% (n=67) of patients had a N0 and N1 disease, respectively. The median number of harvested nodes was 9 and the median number of positive nodes was 2.
Minor and major hepatectomies were performed on 78 (36%) and 138 (64%) of patients, respectively. The median length-of-stay (LoS) was 10 days. While incidence of overall and severe (Clavien-Dindo ≥ 3) complications was 51% (n=109) and 15% (n=33), the incidence of 90-day mortality was 3% (n=7). Patients in the MILS group had more often smaller ICC and underwent more often minor hepatectomies compared with open group patients (all p<0.001). Median number of lymph-node harvested among lap and open patients was 7.9 and 9.2, respectively (p=0.35). Median follow up time was 17 months. After balancing of clinical-pathological variables in a 1:2 PSM, the resulting groups of MILS (n=24) and open (n=48) patients had similar baseline characteristics (all p>0.3). There was no difference in terms of number of lymph-node harvested (p=0.89). There were no differences in terms of 90-day mortality and overall complication (all p>0.49) while MILS patients had fewer severe (Clavien-Dindo ≥3) complications compared with open patients (p=0.02). Moreover, MILS patients had a shorter LOS than open patients (p<0.001). Moreover, there were no differences in terms of overall survival (OS) between the two matched groups (p=0.72). At multivariable analysis, in both unmatched and matched cohort, lymph node status and tumor grading resulted associated with OS (p<0.05).
Discussion: When accurately selected, patients with ICC can safely undergo MILS. Moreover, MILS might result in better short-term outcomes (i.e. shorter LoS and fewer sever complication) for patients undergoing surgery for ICC. Adequate lymph node dissection can be performed with MILS. Oncological outcomes of ICC patients might not be changed by the surgical approach.
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