TRENDS IN MINIMALLY INVASIVE HEPATECTOMY AND BILE DUCT RESECTION FOR INTRAHEPATIC CHOLANGIOCARCINOMA: A RETROSPECTIVE REVIEW
Franklin A. Valdera*3, Elizabeth L. Carpenter3, Ankur Tiwari1, Daniel Nelson2, Guy T. Clifton3, Timothy J. Vreeland3
1The University of Texas Health Science Center at San Antonio, San Antonio, TX; 2William Beaumont Army Medical Center, El Paso, TX; 3Brooke Army Medical Center, Fort Sam Houston, TX
INTRODUCTION
Ideal treatment of hilar cholangiocarcinoma, or intrahepatic cholangiocarcinoma with bile duct involvement, involves hepatectomy and bile duct resection to negative margins, as well as a portal lymphadenectomy. Use of minimally invasive surgery (MIS) is increasingly utilized in cancer operations, but less so for complicated biliary resections. We sought to explore the impact of MIS techniques in combined hepatectomy and bile duct resection.
METHODS
A retrospective review of the NCDB was queried from 2004-2017 for all patients with intrahepatic cholangiocarcinoma who underwent partial hepatectomy and bile duct excision. After applying exclusion criteria, patients were divided into two groups, MIS or open. Conversion to open was included with MIS. The impact of each approach on surgical margins, lymph node yield, unplanned readmission within 30 days of discharge, and survival were explored. Surgical margins were divided into no residual cancer (R0), microscopically residual (R1), macroscopically residual (R2), and residual not otherwise specified (NOS). Lymph node yield was divided into no nodes, 1-3 nodes, and ?4 nodes. Outcomes were analyzed statistically with chi-square and Kaplan-Meier survival analysis.
RESULTS
A total of 353 patients were included in this study, with 55 patients (15.6%) in the MIS group and 298 patients (84.4%) in the open group. A total of 17 patients (31%) from the MIS group were converted to open. The majority (64%) of MIS cases were performed in the last 3 years of collected data (2014-2017). R0, R1 and R2 rates did not differ significantly between MIS and open approaches (R0: 62% vs 65%, R1: 21% vs 21%, R2: 2% vs 1%, p=0.93). Residual disease NOS post-operatively also did not differ (15% vs 13%, p=0.93). There were significant differences in lymph node harvest, with the MIS group yielding fewer lymph nodes than the open group (0 nodes: 37% vs 16.6%, 1-3 nodes: 29% vs 29.8%, ?4 nodes: 34% vs 53.6%, p=0.01). There was a trend towards an increase in the rate of unplanned readmissions within 30 days of discharge in the MIS group relative to the open group, 18.2% of patients vs 9.5% of patients, respectively, p=0.06. Mean overall survival was similar between MIS and open groups (41.7 months and 42.6 months, respectively, p=0.80).
CONCLUSIONS
In a highly selected cohort undergoing MIS hepatectomy with bile duct resection for intrahepatic cholangiocarcinoma, survival and margin outcomes are similar to open surgery. However, the MIS approach yielded significantly fewer lymph nodes. As the MIS approach to complex hepatobiliary resection evolves, an emphasis on adequate portal lymphadenectomy is needed.
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