Laparoscopic liver resections for gallbladder cancer and intrahepatic cholangiocarcinoma: the Mayo clinic experience

Abstract

Presenter: Ron Pery MD | Mayo Clinic, Rochester Background: Gallbladder cancer (GBC) and intrahepatic cholangiocarcinoma (ICC) are aggressive malignancies where surgical resection offers the only meaningful chance of cure. Complete tumor removal with negative margins and adequate porta hepatis lymphadenectomy for tumor staging is the surgical standard of care in resectable cases according to the national comprehensive cancer network (NCCN) guidelines. The safety and oncological adequacy of laparoscopic liver resections for GBC and ICC have been questioned in the past and many surgeons were hesitant to consider it. Being a high-volume center of minimal invasive liver surgeries, this study aimed to describe the Mayo clinic experience with laparoscopic liver resections for GBC and ICC and to specifically ascertain their safety and oncological adequacy. Methods: The Mayo clinic database was used to identify patients who underwent curative intent laparoscopic liver resection for GBC or ICC between 01/2016 to 12/2020. Clinicopathological characteristics, operative details and outcomes of 33 patients were collected and analyzed with specific emphasis on resection margins, porta hepatis lymphadenectomy and post-operative complications. Results: 33 patients with GBC or ICC underwent curative-intent laparoscopic liver resection with or without porta hepatis lymphadenectomy in Mayo clinic between 01/2016 and 12/2020. The median age of patients was 65±11.8. Six (18%) patients underwent major liver resection with porta hepatis lymphadenectomy, fourteen (42%) patients underwent minor liver resection with porta hepatis lymphadenectomy; while five (16%) patients underwent major liver resection and eight (24%) patients underwent minor liver resection without portal lymphadenectomy. The mean operative time was 193 minutes (range 83-881) and the mean estimated blood loss (EBL) was 250cc (range 25-1700). There were two conversions (6%) to laparotomy due to failure to progress. Nineteen (58%) patients had no post-operative complications, five (15%) patients had minor post-operative complications (Clavien Dindo score ≤2) and nine (27%) patients had major post-operative complications (Clavien Dindo score ≥3) including one post-operative mortality (3%) due to portal vein thrombosis leading to fatal liver failure. The median in hospital length of stay was three days (range 1-39). On pathology, the mean tumor size was 36.5mm (range 15-150) and resection margins were negative in all specimens. Amongst the patients who underwent porta hepatis lymphadenectomy, the mean number of harvested lymph nodes was 4.5 (range 1-19) and eight (40%) patients have met the AJCC 8th edition staging manual cutoff of at least six harvested lymph nodes. Conclusion: When done by experienced minimal invasive liver surgeons in a high-volume center, laparoscopic liver resections for GBC and ICC are both feasible, safe and oncologically appropriate. While operative times, EBL and post-operative complications profiles are comparable to historic open controls, the in-hospital length of stay is shorter. As in open surgeries, an effort should be made to meet the AJCC 8th edition recommendation of at least six harvested lymph nodes for adequate tumor staging.