Comparison of Efficacy and Safety Between Laparoscopic and Open Radical Resection for Hilar Cholangiocarcinoma-A Propensity Score-Matching Analysis

Abstract

Background: Radical resection remains the most effective treatment for hilar cholangiocarcinoma (HCCA). However, due to the complex anatomy of the hilar region, the tumor is prone to invade portal vein and hepatic arteries, making the surgical treatment of HCCA particularly difficult. Successful laparoscopic radical resection of HCCA(IIIA, IIIB) requires excellent surgical skills and rich experience. Furthermore, the safety and effectiveness of this operation are still controversial.

Aim: To retrospectively analyze and compare the efficacy and safety of laparoscopic and open surgery for patients with HCCA.

Methods: Clinical imaging and postoperative pathological data of 89 patients diagnosed with HCCA (IIIA, IIIB) and undergoing radical resection in our center from January 2018 to March 2022 were retrospectively analyzed. Among them, 6 patients (4 were lost to follow-up and 2 were pathologically confirmed to have other diseases after surgery) were ruled out, and clinical data was collected from the remaining 83 patients for statistical analysis. These patients were divided into an open surgery group (n=62) and a laparoscopic surgery group (n=21) according to the surgical methods used, and after 1:2 propensity score matching (PSM), 32 and 16 patients respectively in the open surgery group and laparoscopic surgery group were remained. The demographic data, Bismuth type, perioperative data, intraoperative data, postoperative complications, pathological findings, and long-term survivals were compared between these two groups.

Results: After 1:2 PSM, 32 patients in the open surgery group and 16 patients in the laparoscopic surgery group were included for further analysis. Baseline characteristics and pathological outcomes were comparable between the two groups. Statistically significant differences between the two groups were observed in intraoperative blood loss and operative time, as it were 400-800 mL vs 200-400 mL (P=0.012) and (407.97 ± 76.06) min vs (489.69 ± 79.17) min (P=0.001) in the open surgery group and laparoscopic surgery group, respectively. The R0 resection rate of the open group was 28 cases (87.5%), and the R0 resection rate of the laparoscopic group was 15 cases (93.75%). The two groups showed no significant difference in terms of surgical approach, intraoperative blood transfusion, incidence of postoperative complications, and short- and long-term efficacy (P>0.05).

Conclusions: Laparoscopic radical resection of HCCA has comparable perioperative safety compared to open surgery group, as it has less bleeding and shorter operation time. Although it is a promising procedure with the improvement of surgical skills and further accumulation of experience, further investigations are warranted before its wider application.

Keywords: R0 resection; laparoscopic hilar cholangiocarcinoma; open hilar cholangiocarcinoma; propensity score matching; retrospective study.

Figure 1

Flow chart of patient enrollment.

Figure 2

Procedure of laparoscopic hilar cholangiocrinoma 1. (A) three-dimensional (3D) imaging of the tumor (red arrow); (B) Trocar placement during laparoscopic radical resection for HCCA. The chief operator stands on the right side of the patient, inserting 5-mm and 12-mm trocars into the right abdomen; the first assistant stands on the patient’s left side, placing 5-mm and 12-mm trocars above the umbilicus and on the left abdomen; and the camera-holder stands between the two legs of the patient(yellow arrow). (C) sever the lower end of the common bile duct at the upper border of the pancreas; (D) transect the right hepatic artery(yellow arrow); (E) dissect the lymph nodes in the hilar region(yellow arrow); (F) transect the right hepatic duct(yellow arrow); (G) identify the left branch of portal vein and portal vein (yellow arrow); (H) identify the right branch of portal vein (yellow arrow). CBD, Common bile duct; RHA, Right hepatic artery; RHD, Right hepatic duct; LPV, Left branch of portal vein; PV, Portal vein; RPV, Right branch of portal vein.

Figure 3

Procedure of laparoscopic hilar cholangiocrinoma 2. (A–C) resection and reconstruction of left branch of portal vein; (D) liver parenchyma transection-priority approach for liver resection; (E) transection of right hepatic vein using a cutter/staple; (F–H) hepatobliary duct-jejunum anastomosis (placement of T tube). LPV, Left branch of portal vein; PV, Portal vein; LHD,left hepatic duct.

Figure 4

Comparisons of overall survival and disease-free survival using Kaplan-Meier curves. (A) the 1- year survival rates were 92.28% in the OS group and 91.67% in the LS group, and 2-year survival rates was 35.16% in the OS group and 34.37% in the LS group (P=0.536). (B) The 1-year disease-free survival (DFS) rate was 82.16% in the OS group and 82.96% in the LS group, and the 2-year DFS rate was 38.64% in the OS group and 46.09% in the LS group (P=0.911).