Surgery For Cholangiocarcinoma Research Articles

Significance of the modified global leadership initiative on malnutrition (GLIM) criteria malcondition for patients with biliary tract cancer.

This study investigated the significance of the Global Leadership Initiative on Malnutrition (GLIM) for patients with resected biliary tract cancers. The subjects of this retrospective analysis were 114 patients who underwent radical surgery for cholangiocarcinoma between 2018 and 2023. We analyzed both handgrip force and skeletal muscle area and classified patients as having GLIM malnutrition or modified GLIM malcondition. We also evaluated clinicopathological factors, short-term outcomes, and prognoses. The GLIM criteria identified 47 patients (41.2%) with malnutrition and 13 patients (11.4%) with modified GLIM malcondition. Overall survival (P = 0.009) and recurrence-free survival (P = 0.016) were significantly different between the well-nourished and malnourished patients according to the GLIM criteria. Furthermore, modified GLIM criteria malcondition was a significant prognostic factor for both recurrence-free and overall survival (P = 0.002 and P < 0.001, respectively). Multivariate analysis identified a higher carcinoembryonic antigen level and modified GLIM malcondition as predictors of overall and recurrence-free survival. Pathological stage ≥ III was also a predictor of recurrence-free survival. On comparing the prognoses of modified GLIM malcondition and GLIM malnutrition using the Akaike Information Criteria, the modified GLIM malcondition was identified as a stronger prognostic factor. A modified GLIM malcondition can be a highly useful prognostic marker for patients with resected biliary tract cancer.

Comparison of robot-assisted, open, and laparoscopic-assisted surgery for cholangiocarcinoma: a network meta-analysis.

The aim of this study is to compare the efficacy of robot-assisted, laparoscopic-assisted and open surgery in the treatment of cholangiocarcinoma, and to evaluate the clinical effect of three surgical methods in the treatment of cholangiocarcinoma by network Meta-analysis. A systematical retrieval in PubMed and Web of Science was performed for relative literature on the effects of robot-assisted(RA), laparoscopy-assisted(LA), and open surgery(OA) for cholangiocarcinoma in treating cholangiocarcinoma. A literature search updated to September 1st, 2024, was performed. Studies have shown that the length of R0 resection, complication rate, 30-day mortality, Transfusion rate, Lymph Node Metastasis Rate, and hospital stay in RA are superior to LA and open surgery. The relative effectiveness of the three surgical methods in terms of operation time were: open surgery, laparoscope-assisted surgery, and robot-assisted surgery, and there was no significant difference among the three groups. Robot-assisted surgery is safe and feasible in the treatment of cholangiocarcinoma, but more clinical evidence is needed to confirm these findings.

New criteria for preoperative liver function assessment with safety margins to avoid postoperative mortality during liver resection for hilar cholangiocarcinoma

BackgroundDespite recent medical advancements, surgery for hilar cholangiocarcinoma is associated with high complication and mortality rates. This may be partly attributed to the absence of established preoperative liver evaluation criteria for safe surgery. This study aimed to propose a reliable indicator for safe and well-planned management of major hepatectomy with extrahepatic bile duct resection. MethodsWe included 150 patients who underwent major hepatectomy with extrahepatic bile duct resection between 2013 and 2021 in Japan. The risk factors for post-hepatectomy liver failure (PHLF) were retrospectively analyzed. ResultsPHLF was observed in 24 (16.0 %) patients who underwent major hepatectomy with extrahepatic bile duct resection. In the multivariate analysis, the identified risk factors for PHLF were the ratio of future remnant liver volume to total liver volume (FRLV/TLV) ≤ 42 % and indocyanine green clearance fraction of the future remnant liver (ICGK-F) ≤ 0.07. Patients with these two factors were significantly associated with PHLF compared with those with either one or none of the risk factors (60.0 % vs 15.1 % and 8.1 %, respectively). ConclusionThe combinational use of ICGK-F and FRLV/TLV is useful for preoperative liver function assessment with a safety margin to avoid PHLF and postoperative mortality in hepatectomy for hilar cholangiocarcinoma.

Prognostic value of the advanced lung cancer inflammation index in intrahepatic cholangiocarcinoma

IntroductionThe advanced lung cancer inflammation index (ALI), which combines inflammation and nutrition data, was recently proposed as a prognostic biomarker. We assessed the impact of ALI on overall survival (OS) among patients undergoing surgery for intrahepatic cholangiocarcinoma (ICC). MethodsPatients who underwent surgery for ICC were identified from an international cohort. ALI was calculated as body-mass index (BMI)∗albumin/neutrophil-to-lymphocyte ratio; patients were categorized into “low-” and “high-ALI” using log-rank statistics. The impact of ALI on OS was compared against other inflammatory markers (i.e., neutrophil-to-lymphocyte ratio [NLR], platelet-to-lymphocyte ratio [PLR], systemic immune inflammation index [SII = platelets∗NLR]) using Harrell's Concordance index (C-index) and the Akaike Information Criterion (AIC). To minimize intergroup differences, propensity score matching was employed. ResultsAmong 1045 patients, more than one-half of individuals underwent major hepatectomy (n = 582, 55.7 %), median tumor size was 5.5 cm (IQR, 3.8–7.8), and median ALI was 38.9 (IQR 26.5–57.2). On multivariate analysis, low ALI was an independent risk factor for worse OS (HR 1.21, 95 % CI 1.01–1.46; p = 0.04). Patients with low ALI had worse 5-year OS (36.9 % vs. 49.9 %; p < 0.001), which remained significant after PSM (36.9 % vs. 41.3 %; p = 0.039). ALI had a comparable discriminatory ability compared with NLR, PLR, and SII (C-index: 0.646 vs. 0.644 vs. 0.640 vs. 0.641, respectively), yet had a lower AIC (5475.31 vs. 5546.80 vs. 5550.45 vs. 5548.62, respectively) suggesting slightly better model fit and accuracy. ConclusionsALI was an independent predictor of OS among patients undergoing surgery for ICC. Nutritional and inflammatory markers should be incorporated into predictive models to improve prognostic stratification.

The association between myosteatosis and gamma-glutamyltransferase in patients undergoing surgery for cholangiocarcinoma: A predictive analysis

The association between myosteatosis and gamma-glutamyltransferase in patients undergoing surgery for cholangiocarcinoma: A predictive analysis

Development and Validation of a Predictive Risk Score for Blood Transfusion in Patients Undergoing Curative-Intent Surgery for Intrahepatic Cholangiocarcinoma.

Among patients undergoing liver resection for intrahepatic cholangiocarcinoma (ICC), perioperative bleeding requiring blood transfusion is a common complication, yet preoperative identification of patients at risk for transfusion remains challenging. The objective of this study was to develop a preoperative risk score for blood transfusion requirement during surgery for ICC. Patients undergoing curative-intent liver surgery for ICC (1990-2020) were identified from a multi-institutional database. A predictive model was developed and validated. An easy-to-use risk calculator was made available online. Among 1420 patients, 300 (21.1%) received an intraoperative transfusion. Independent predictors of transfusion included severe preoperative anemia (OR = 1.65, 95% CI 1.10-2.47), T2 category or higher (OR = 2.00, 95% CI 1.36-3.02), positive lymph nodes (OR = 1.75, 95% CI 1.32-2.32) and major resection (OR = 2.56, 95%CI 1.85-3.58). Receipt of blood transfusion significantly correlated with worse outcomes. The model showed good discriminative ability in both training (AUC = 0.68, 95% CI 0.66-0.72) and bootstrapping validation (C-index = 0.67, 95% CI 0.65-0.70) cohorts. An online risk calculator of blood transfusion requirement was developed (https://catalano-giovanni.shinyapps.io/TransfusionRisk). Intraoperative blood transfusion was significantly associated with poor postoperative outcomes among patients undergoing surgery for ICC. The identification of patients at high risk of transfusion could improve perioperative patient care and blood resources allocation.

Upfront surgery for intrahepatic cholangiocarcinoma: Prediction of futility using artificial intelligence

ObjectiveWe sought to identify patients at risk of “futile” surgery for intrahepatic cholangiocarcinoma using an artificial intelligence (AI)–based model based on preoperative variables. MethodsIntrahepatic cholangiocarcinoma patients who underwent resection between 1990 and 2020 were identified from a multi-institutional database. Futility was defined either as mortality or recurrence within 12 months of surgery. Various machine learning and deep learning techniques were used to develop prediction models for futile surgery. ResultsOverall, 827 intrahepatic cholangiocarcinoma patients were included. Among 378 patients (45.7%) who had futile surgery, 297 patients (78.6%) developed intrahepatic cholangiocarcinoma recurrence and 81 patients (21.4%) died within 12 months of surgical resection. An ensemble model consisting of multilayer perceptron and gradient boosting classifiers that used 10 preoperative factors demonstrated the highest accuracy, with areas under receiver operating characteristic curves of 0.830 (95% confidence interval 0.798–0.861) and 0.781 (95% confidence interval 0.707–0.853) in the training and testing cohorts, respectively. The model displayed sensitivity and specificity of 64.5% and 80.0%, respectively, with positive and negative predictive values of 73.1% and 72.7%, respectively. Radiologic tumor burden score, serum carbohydrate antigen 19-9, and direct bilirubin levels were the factors most strongly predictive of futile surgery. The artificial intelligence–based model was made available online for ease of use and clinical applicability (https://altaf-pawlik-icc-futilityofsurgery-calculator.streamlit.app/). ConclusionThe artificial intelligence ensemble model demonstrated high accuracy to identify patients preoperatively at high risk of undergoing futile surgery for intrahepatic cholangiocarcinoma. Artificial intelligence–based prediction models can provide clinicians with reliable preoperative guidance and aid in avoiding futile surgical procedures that are unlikely to provide patients long-term benefits.

Preoperative platelet count as an independent predictor of long-term outcomes among patients undergoing resection for intrahepatic cholangiocarcinoma.

An elevated platelet count may reflect neoplastic and inflammatory states, with cytokine-driven overproduction of platelets. The objective of this study was to evaluate the prognostic utility of high platelet count among patients undergoing curative-intent liver surgery for intrahepatic cholangiocarcinoma (ICC). An international, multi-institutional cohort was used to identify patients undergoing curative-intent liver resection for ICC (2000-2020). A high platelet count was defined as platelets >300 *109/L. The relationship between preoperative platelet count, cancer-specific survival (CSS), and overall survival (OS) was examined. Among 825 patients undergoing curative-intent resection for ICC, 139 had a high platelet count, which correlated with multifocal disease, lymph nodes metastasis, poor to undifferentiated grade, and microvascular invasion. Patients with high platelet counts had worse 5-year (35.8% vs. 46.7%, p = 0.009) CSS and OS (24.8% vs. 39.8%, p < 0.001), relative to patients with a low platelet count. After controlling for relevant clinicopathologic factors, high platelet count remained an adverse independent predictor of CSS (HR = 1.46, 95% CI 1.02-2.09) and OS (HR = 1.59, 95% CI 1.14-2.22). High platelet count was associated with worse tumor characteristics and poor long-term CSS and OS. Platelet count represents a readily-available laboratory value that may preoperatively improve risk-stratification of patients undergoing curative-intent liver resection for ICC.

Efficacy and Safety of Robotic Surgery vs. Open Surgery for Hilar Cholangiocarcinoma: A Comprehensive Review.

Hilar cholangiocarcinoma, a rare and aggressive bile duct malignancy, presents significant challenges in surgical management. Traditionally treated with open surgery, the emergence of robotic surgery has introduced a new dimension to surgical approaches for this condition. This review aims to systematically compare the efficacy and safety of robotic surgery versus open surgery for hilar cholangiocarcinoma. We conducted a comprehensive review of the literature, including clinical studies, case series, and comparative analyses of robotic and open surgical techniques. Data on oncological outcomes, functional recovery, survival rates, complications, and cost-effectiveness were extracted and analyzed to provide a detailed comparison of the two surgical approaches. Robotic surgery offers several potential advantages over open surgery, including reduced intraoperative blood loss, smaller incisions, and shorter recovery times. However, it requires specialized training and has a higher initial cost. Open surgery, while more established and broadly practiced, remains associated with longer recovery periods and higher complication rates. Oncological outcomes, such as R0 resection rates and survival, appear comparable between the two approaches, though robotic surgery may offer improvements in functional recovery and postoperative quality of life. Both robotic and open surgery have their merits in the treatment of hilar cholangiocarcinoma. Robotic surgery presents promising benefits in terms of reduced invasiveness and improved recovery, while open surgery continues to be a reliable and well-established option. The choice of surgical approach should be guided by patient-specific factors, surgeon expertise, and institutional resources. Further research is needed to refine surgical techniques and establish long-term outcomes, which will aid in optimizing treatment strategies for this challenging malignancy.

Efficacy and safety of robotic surgery versus open surgery for hilar cholangiocarcinoma: a systematic review and meta-analysis.

The aim is to assess and contrast the effectiveness and safety of employing robotic surgery versus traditional open surgery in managing cases of hilar cholangiocarcinoma. Computer searches were conducted in PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), and Wanfang Database to identify case-control studies comparing robotic surgery with traditional open surgery in the treatment of hilar cholangiocarcinoma from inception until July 2023. References from retrieved articles were reviewed to broaden the search. This review was prospectively registered in the PROSPERO database (PROSPERO ID: CRD42024527511) and reported in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) Guidelines.The primary outcome measures included operation time, intraoperative blood transfusion rate, R0 resection rate, lymph node metastasis rate, incidence of postoperative complications, and postoperative hospital stay. Data analysis was performed using RevMan 5.4 software, calculating combined odds ratios (OR), mean differences (MD), and 95% confidence intervals (95% CI). A total of 4 studies encompassing 267 patients diagnosed with hilar cholangiocarcinoma (177 males and 90 females, mean age of (58.8±5.7) years) were included in this analysis. Among these, 165 patients underwent open surgery, while 102 patients underwent robotic surgery. The results of the meta-analysis demonstrated comparable outcomes between the two groups. Specifically, the operation time between the robotic surgery and open surgery cohorts did not significantly differ (MD=-103.96, 95% CI: -216.90 to 8.98, P=0.070). Additionally, the intraoperative blood transfusion rate (OR=1.32, 95% CI: 0.43 to 4.07, P=0.630), R0 resection rate (OR=1.41, 95% CI: 0.71 to 2.81, P=0.330), and lymph node metastasis rate (OR=1.62, 95% CI: 0.46 to 5.63, P=0.450) showed no significant differences between the groups. Similarly, there were no statistically significant disparities observed in the incidence of postoperative complications (OR=0.60, 95% CI: 0.28 to 1.31, P=0.200) and postoperative hospital stay (MD=2.17, 95% CI: -11.56 to 15.90, P=0.760). In the treatment of hilar cholangiocarcinoma, robotic surgery demonstrates comparable safety and feasibility to traditional open surgery. However, due to the limited quantity and quality of the included studies, these conclusions warrant validation through additional high-quality investigations.

Meta-analysis of short-term and long-term outcomes of robot-assisted and open radical surgery for hilar cholangiocarcinoma

Aim. To review the comparative studies into robot-assisted and open surgeries for hilar cholangiocarcinoma. Materials and methods. Search for the comparative studies into the results of robot-assisted and open surgeries in patients with hilar cholangiocarcinoma was performed using electronic databases Embase, MEDLINE, Web of Science and Google Scholar by keywords “robotic” AND “hilar cholangiocarcinoma” OR “perihilar cholangiocarcinoma” OR “Klatskin tumor” published by December 31, 2023. Results. The meta-analysis involves the results of 169 resections, including 53 robot-assisted and 116 open surgeries. Robot-assisted interventions revealed longer surgery duration (weighted mean difference (WMD) = 157.49, CI = 95 % [102.85; 212.12], р &lt; 0.00001), less amount of intraoperative blood loss, close to statistically significant (WMD = −76.41, CI = 95 % [−159.90; 7.08], р = 0.07). Robot-assisted and open surgery groups appear comparable in terms of their perioperative parameters, including blood transfusion rate, number of R0 resections, number of lymph nodes removed, rate of postoperative complications, length of hospital stay, in-hospital mortality, as well as overall and event-free survival rates. Conclusion. Meta-analysis of short-term and long-term outcomes of robot-assisted and open surgeries for hilar cholangiocarcinoma of the liver and bile ducts proves the potential and possibility for using robotic technologies in selective patients.

Current status and future perspectives of robotic liver surgery.

Robotic liver resection has been reported in case series since the early 2000s. The surgical robot is capable of precise operation using articulated forceps with seven degrees of freedom. The robot also eliminates tremors and provides a good surgical field with highly detailed 3D high-definition images. The clinical results demonstrating their usefulness have been increasing year by year. Initially, a shorter hospital stay was observed in comparison with open hepatectomy. Recent reports have also shown lower conversion and complication rates in comparison with laparoscopic hepatectomy. The clamp and crush method with bipolar forceps, sealing devices, ultrasonic shears, and the combined procedure of Cavitron ultrasonic surgical aspirator and robotic forceps as hybrid procedures have been reported as effective methods of parenchymal transection in robotic surgery. Theoretically, the advantages of the robotic platform allow for more complex liver resection around hilar structures and major blood vessels, as well as for vascular reconstruction or biliary reconstruction. The application of robotic liver surgery for hilar cholangiocarcinoma, living donor hepatectomy, and living donor liver transplantation has been reported. Robotic liver surgery is becoming more popular for certain indications; however, it is important to further evaluate its long-term surgical and oncological outcomes and costs in comparison with conventional laparoscopic and open liver surgery, based on accumulated experience.

Robotic-assisted radical resection versus open surgery for cholangiocarcinoma: a systematic review and meta-analysis.

To compare the clinical efficacy and safety of robot-assisted resection and open surgery for cholangiocarcinoma (CCA). We conducted a comprehensive search of PubMed, the Cochrane Library, and Embase databases for studies comparing treatment for CCA, covering the period from database inception to January 30, 2024. Two researchers will independently screen literature and extract data, followed by meta-analysis using Review Manager 5.3 software. A total of 5 articles with 513 patients were finally included. Among them, 231 in the robotic group, and 282 in the open group. The Meta-analysis revealed that the robotic group had a significant advantage in terms of intraoperative blood loss (MD = -101.44, 95% CI -135.73 to -67.15, P < 0.05), lymph node harvest(MD = 1.03, 95% CI 0.30-1.76, P < 0.05) and length of hospital stay(MD = -1.92, 95% CI -2.87 to-0.97, P < 0.05). However, there were no statistically significant differences between the two groups in terms of transfusion rate (OR = 0.62, 95% CI 0.31-1.23, P > 0.05), R0 resection (OR = 1.49, 95% CI 0.89- 2.50, P > 0.05), 30-day mortality (OR = 1.68, 95% CI 0.43-6.65, P > 0.05) and complications (OR = 0.76, 95% CI 0.30- 1.95, P > 0.05). Robotic-assisted radical resection for CCA is feasible and safe, and its long-term efficacy and oncological outcomes need to be confirmed by further studies.

Surgical strategy for incidental intrahepatic cholangiocarcinoma in terms of lymph node dissection

BackgroundAlthough many guidelines recommend performing lymph node dissection (LND) during surgery for intrahepatic cholangiocarcinoma (ICC), there is no evidence for patients with incidentally detected ICC who did not undergo LND. This study aimed to identify the role of LND in patients with incidental ICC. MethodsThe data from 284 patients who had undergone radical surgery for ICC from 2000 to 2020 were retrospectively reviewed. The enrolled patients were divided into 3 groups according to their T stage (T1 vs T2 vs T3 + 4). Moreover, the patients of each T group were divided into 3 groups according to their nodal status (N0 vs N1 vs Nx) and their survival outcomes were compared. ResultsSurvival outcomes of Nx group were statistically similar to that of N0 group in T1 stage (Nx vs N0: disease-free survival [DFS] [months], 129.0 [75.6–182.4] vs 125.0 [65.7–184.3], P = .948; overall survival [OS] [months], 175.0 [153.9–196.1] vs 173.0 [109.0–237.0], P = .443). In contrast, survival outcomes of Nx group in the other T stage (T2 and T3 + 4) were poorer than that of N0 group and were better than that of N1 group. In addition, in the Nx subgroup analysis according to T stage, T1 group showed significantly better survival outcomes than the other groups (T1 vs T2 vs T3 + 4: DFS [months], 129.0 [75.9–182.1] vs 16.0 [9.8–22.2] vs 13.0 [0.3–25.7], P < .001; OS [months], 175.0 [153.9–196.1] vs 53.0 [30.8–75.2] vs 37.0 [17.6–56.4], P < .001). ConclusionPatients with ICC incidentally diagnosed as having T2 or above T stage may consider additional LND.

Prevention and treatment of severe complications after radical surgery for portal cholangiocarcinoma

Aim. To develop the concept of prevention and treatment of severe complications after radical surgery for portal cholangiocarcinoma based on a comparative analysis of two periods of the surgical treatment program. Materials and methods. The study involved an analysis of multidisciplinary treatment of patients with portal cholangiocarcinoma for 8 years (2013–2020). The study consisted of two stages: program formation in 2013–2018 and evaluation of results in 2019–2020. Results. 140 patients with portal cholangiocarcinoma underwent radical or relatively radical surgery: 94 patients in the first period and 46 patients in the second period. 35 pairs of observations were formed by means of propensity score matching. In the second period, the incidence of Clavien-Dindo grade IV and V complications, CCI&gt;40 index, duration of stay in the intensive care unit, and 90-day mortality significantly decreased. Proven reasons for the improvements included more thorough preparation of patients for the resection stage of treatment, elimination of clinical and laboratory manifestations of biliary drainage complications, careful invasive monitoring of fluid accumulations, and prevention of cholangitis. Conclusion. Maximum compensation of inflammatory and trophic disorders, elimination of jaundice, prevention and early elimination of complications as a result of their prognosis and monitoring at all stages of treatment reliably improve the immediate results of radical surgery for portal cholangiocarcinoma.

Survival analysis of laparoscopic surgery and open surgery for hilar cholangiocarcinoma: a retrospective cohort study

Background/purposeThis study compared the clinical efficacy and safety of laparoscopic versus open resection for hilar cholangiocarcinoma (HCCA) and analyzed potential prognostic factors.MethodsThe study included patients who underwent HCCA resection at our center from March 2012 to February 2022. Perioperative complications and postoperative prognosis were compared between the laparoscopic surgery (LS) and open surgery (OS) groups.ResultsAfter screening 313 HCCA patients, 68 patients were eligible for the study in the LS group (n = 40) and OS group (n = 28). Kaplan-Meier survival curve analysis revealed that overall survival > 2 years and 3-year disease-free survival (DFS) were more common in the LS than OS group, but the rate of 2-year DFS was lower in the LS group than OS group. Cox multivariate regression analysis revealed age (< 65 years), radical resection, and postoperative adjuvant therapy were associated with reduced risk of death (hazard ratio [HR] = 0.380, 95% confidence interval [CI] = 0.150–0.940, P = 0.036; HR = 0.080, 95% CI = 0.010–0.710, P = 0.024 and HR = 0.380, 95% CI = 0.150–0.960, P = 0.040), whereas preoperative biliary drainage was an independent factor associated with increased risk of death (HR = 2.810, 95% CI = 1.130–6.950, P = 0.026). Perineuronal invasion was identified as an independent risk factor affecting DFS (HR = 5.180, 95% CI = 1.170–22.960, P = 0.030).ConclusionsCompared with OS, laparoscopic HCCA resection does not significantly differ in terms of clinical efficacy. Age (<65 years), radical resection, and postoperative adjuvant therapy reduce the risk of death, and preoperative biliary drainage increases the risk of death.

Multimodal prehabilitation program in patients with resectable perihilar cholangiocarcinoma: keypoints for an implementation protocol and literature review.

Postoperative complications after perihilar cholangiocarcinoma surgical procedure are still very high. The implementation of a multimodal prehabilitation program could improve these outcomes. Based on our experience and that of the literature in hepatobiliary and pancreatic surgery, we propose a protocol to promote its implementation. First, we performed a retrospective analysis of the implementation feasibility of a multimodal prehabilitation program in patients' candidates for elective perihilar cholangiocarcinoma surgery in our center. Second, we conducted a literature search of publications in PubMed until December 2022. Relevant data about hepato-pancreato-biliary surgery and prehabilitation programs in features and postoperative outcomes was analyzed. Since October 2020, 11 patients were evaluated for prehabilitation in our hospital. Two of them could not be resected intraoperatively due to disease extension. The median hospital stay was 10days (iqr, 7-11). There were no major complications and 1 patient died. Of a total of 17 articles related to prehabilitation in hepato-biliary-pancreatic surgery, no reports focusing exclusively on perihilar cholangiocarcinoma were found. Six of the studies had nutritional therapies in addition to physical interventions, and 12 studies used home-based exercise therapy. Based on our experience and the data obtained from other studies, a prehabilitation program could be useful to improve perioperative physical and mental fitness in patients' candidates for elective perihilar cholangiocarcinoma surgery. However, more well-designed studies are needed to allow us to obtain more evidence.

ASO Visual Abstract: Minimally Invasive Approach Provides Oncological Benefit in Patients with High Risk of Very Early Recurrence (VER) After Surgery for Intrahepatic Cholangiocarcinoma (iCCA).

ASO Visual Abstract: Minimally Invasive Approach Provides Oncological Benefit in Patients with High Risk of Very Early Recurrence (VER) After Surgery for Intrahepatic Cholangiocarcinoma (iCCA).

Minimally Invasive Approach Provides Oncological Benefit in Patients with High Risk of Very Early Recurrence (VER) After Surgery for Intrahepatic Cholangiocarcinoma (iCCA).

Surgery for intrahepatic cholangiocarcinoma (iCCA) is jeopardized by significant risk of early recurrence (≤ 6 months). The aim of the present study is to analyze the oncological benefit provided by laparoscopic over open approach for iCCA in patients with high risk of very early recurrence (VER). A total of 532 liver resections (LR) were performed for iCCA [265 by minimally invasive surgery (MIS) and 267 with open approach, matched through a 1:1 propensity score] and stratified using the postoperative prediction model of VER. Outcomes were compared between open and laparoscopic approaches, specifically evaluating oncological benefit. The percentage of patients with high risk of VER was similar (32.7% in the laparoscopic group and 35.3% in the open group, pNS). The number of retrieved nodes as well as the rate and depth of negative resection margins were comparable between laparoscopic and open. The surgery-adjuvant treatment interval was shorter in laparoscopic patients in the overall series, as well in the subgroup of high risk of VER. The rate of patients starting adjuvant treatments within 2 months from surgery was higher in laparoscopic group compared with open group. In VER high-risk group both disease-free survival (DFS) and overall survival (OS) were significantly improved in MIS compared with open group (p = 0.032 and p = 0.026, respectively). In patients with high risk of VER, laparoscopy translates into an advantage in terms of recurrence-free survival, likely related to lower biological impact of surgery, together with a shorter interval between surgery and start of adjuvant treatments, even allowing for a higher number of patients to start adjuvant therapies within 2 months from resection.

Minimally invasive approach provides oncological benefit in patients with high risk of very early recurrence (VER) after surgery for intrahepatic cholangiocarcinoma (iCCA): a propensity-score based, matched analysis

Minimally invasive approach provides oncological benefit in patients with high risk of very early recurrence (VER) after surgery for intrahepatic cholangiocarcinoma (iCCA): a propensity-score based, matched analysis