Minimally Invasive Approaches to Intrahepatic and Extrahepatic Cholangiocarcinoma

Andrew A Gumbs, MD, Nicolas Jarufe, MD, Brice Gayet, MD PhD. Summit Medical Group, Pontificia Universidad Católica School of Medicine, Institut Mutualiste Montsouris


Introduction: Due to the perceived difficulty in dissecting hilar cholangiocarcinomas off of the portal structures and in performing complex biliary reconstructions, very few centers have used minimally invasive techniques for these tumors. Furthermore, due to the relative rarity of this tumor when compared to hepatocellular carcinoma, only a few reports have focused on short and long-term results for intrahepatic cholangiocarcinoma.

Methods: Because of this, a review was undertaken by combining the experience of 3 international centers with expertise in complex minimally invasive hepatobiliary surgery. Patients were entered into a database retrospectively, all patients with cholangocarcinoma were analyzed. Patients were divided into hilar cholangiocarcinomas and intrahepatic cholaniocarcinomas. The Bismuth classification was used to stratify the hilar cholangiocarcinomas.

Results: From December 2002- June 2011, a total of 14 patients were resected laparoscopically for cholangiocarcinoma. Nine patients had an intrahepatic lesion. Their mean age was 69 years (range= 48-86 years). Three patients (75%) required an extended major hepatectomy, 4 a major hepatectomy and 2 underwent minor hepatectomies. Eight patients with intrahepatic disease were stage I with 1 patient having stage II disease. This last patient had 3 lesions in segment IVb and had an R2 resection. Of the remaining patients, 7 had R0 resections with a final patient found to have R1 disease on final pathology. The mean resection margin was 11mm (range= 0-30mm). The median size of lesions resected was 67 mm (range= 30-70mm). The mean estimated blood loss (EBL) was 233 mL (range= 100-400mL). The median length of stay (LOS) was 11 days (range=6-21 days). Six out of 9 patients are currently alive with a median follow-up of 28 months. Five patients had a hilar lesion, their mean age was 73 years (range= 66-79 years). These patients had stage IIa (2 patients), IIIa, IIIb and IV, respectively. One of these patients (20%) was converted to an open procedure due to concerns for portal vein involvement. The patient with stage IV disease had an R1 resection on final pathology all other patients had R0 resections. The mean EBL was 240 mL (range=0-400 mL), the median LOS was 15 days (range=11-21 days). All patients are currently alive with a median follow up of 11 months (range= 3-18 months). None of the 14 patients developed port site recurrences. No patients required reoperation, but 2 patients developed bile leaks and a final patient developed a pulmonary embolism for an overall morbidity rate of 21%. The overall conversion rate was 7%. There were no mortalities at 30 or 90 days.

Discussion: Minimally invasive approaches for both intrahepatic and hilar cholangiocarcinomas appear feasible and safe. There is no increased rate of port site recurrences when cholangiocarcinomas are removed laparoscopically. Although short term results seem similar to the published open experience, longer-term follow-up is needed to see how disease free and overall survival is affected.

Session Number: SS03 – HPB (Hepatobiliary and Pancreas)
Program Number: S015

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