Laparoscopic liver resection for intrahepatic cholangiocarcinoma

Abstract

Background: Cholangiocarcinoma is the most common biliary tract malignancy, and the second most common type of primary liver cancer. It is more common in Asia but its incidence in North America is increasing. CCA can be categorized as intrahepatic (iCCA) or extrahepatic (perihilar – pCCA/distal – dCCA). There are three main staging systems: American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC); Liver Cancer Study Group of Japan (LCSGJ); and National Cancer Center of Japan (NCCN). Its clinical presentation is unspecific, and it varies depending on tumor location and stage disease. Combined interpretation with different diagnostic modalities is necessary. Methods: A 73-year-old female presented with mild abdominal discomfort and back pain to her primary care physician. Laboratorial exams were requested, and elevated liver enzymes were noted. Abdominal ultrasound was performed that showed left-sided bile duct dilation. Patient underwent an abdominal MRI that identified tortuous and markedly dilated left intrahepatic bile ducts with lobular enhancing intraductal mass with restricted diffusion in the left main hepatic duct measuring approximately 2.3 x 0.9 x 0.8 cm. ERCP with biopsy was made, and a polypoid lesion in the left bile duct was seen. The papillary epithelium was consistent with high-grade dysplasia with possible intraductal papillary neoplasm or cholangiocarcinoma. Laparoscopic surgery was indicated. Patient underwent a cholecystectomy, hepatoduodenal lymphadenectomy, left hepatectomy, and en bloc caudate resection. Results: The Patient was in supine position. General anesthesia was induced. A supraumbilical incision was made. The abdomen was entered without difficulty. Hasson trocar was placed, pneumoperitoneum established. The laparoscope was induced, and the abdomen was explored. The patient had no signs of metastatic or peritoneal disease. The left lobe appeared atrophied, and the right lobe appeared quite hypertrophied. No signs of underlying liver disease. Therefore, 2 additional right-sided 12-mm trocars, an epigastric 5 and a left side 5 trocars were placed. An enlarged hepatic artery lymph node was identified, resected and sent for frozen, it was negative for neoplasia. Cholecystectomy and hepatoduodenal lymphadenectomy were performed. The intrahepatic lesion was resectable, and the caudate lobe appeared potentially involved. It was decided to perform a left hepatectomy with en bloc caudate lobe resection. Specimen was analyzed by Pathology, that confirmed grossly and microscopically widely negative margins. The surface of the liver was cut, and packed with gauze and Surgicel. This was completely dry. There was adequate arterial and portal inflow with biliary drainage to the right lobe of the liver, and no sign of bile leak. Surgicel SNoW and Surgicel gauze were placed against the cut surface of the liver, and closed the specimen extraction site with multiple figure-of-eight 0 Vicryl sutures, and desufflated the abdomen through the trocars, removed the trocars, and closed the 12-mm trocar with a single interrupted 0 Vicryl, and closed the skin with running 4-0 subcuticular stitch and covered with Dermabond. Counts were reported as correct. No complications. No drains. Estimated blood loss was 300 mL. Patient tolerated the surgery well, and was discharged on postoperative day 3. Conclusion: Surgery is the only potentially curative therapeutic option for Cholangiocarcinoma. Minimally invasive approach is challenging, and not widely performed by surgeons. It requires expertise in liver and laparoscopic technique. Despite this, it is feasible, and safe for intrahepatic Cholangiocarcinoma. There are no differences in oncologic outcomes. Blood loss seems to be higher when open surgery is performed, and lymphadenectomy higher in minimally invasive approaches. There are no significant differences between length of hospital stay and complication rates. Laparoscopic liver resection is a treatment modality that should be considered for selected patients with intrahepatic cholangiocarcinoma.