de Hondt Joey, Zwart Maurice J W, Uijterwijk Bas A, Burchell George L, Görgeç Burak, Zonderhuis Babs, Kazemier Geert, Erdmann Joris, Besselink Marc G, Swijnenburg Rutger-Jan
Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands.
Cancer Center Amsterdam, Amsterdam, the Netherlands.
Surg Endosc. 2025 Sep 10. doi: 10.1007/s00464-025-11900-4.
The implementation of minimally invasive liver surgery (MILS) for perihilar (PHC) and intrahepatic cholangiocarcinoma (IHC) remains limited and a systematic review including only comparative studies of MILS versus the open approach is lacking. This systematic review and meta-analysis aimed to assess the safety and efficacy of minimally invasive surgery in patients with hilar and intrahepatic cholangiocarcinomas.
Systematic review in the PubMed, Embase, and Cochrane databases for original studies comparing at least five patients undergoing MILS with open liver surgery for PHC and IHC. Meta-analysis included the primary outcomes of morbidity and mortality. Secondary outcomes included post-operative outcomes, recurrence, disease-free survival, and resection margins.
Overall, 37 comparative non-randomised studies with 4863 patients were included, of which 24% PHC and 76% IHC. In 21 studies, propensity score matching was performed. In total, 2106 laparoscopic, 75 robotic, and 2662 open procedures were analysed. The conversion rate was median 11.5% [IQR 10.0-12.5]. MILS probably resulted in reduced rates of major morbidity, 13.3% vs 18.8% (OR 0.75, 95%CI 0.62-0.90), mortality, 3.0% vs 4.5% (OR 0.69, 95%CI 0.49-0.97), and shorter hospital stay, 8.0 vs 10.9 days (MD -2.1, 95%CI -2.8 - -1.5). MILS resulted in higher rate of R0 resections in PSM cohort, 90.4% vs 81.4%, (OR 1.40, 95%CI 1.13-1.74) and better 3-year disease-free survival rate (49.9% vs 38.5%, HR 3.2, 95%CI 3.1-3.3). In the subgroup of 1180 patients in whom a hepatico-jejunostomy was performed (498 laparoscopic, 65 robotic, 617 open) MILS remained associated with reduced major morbidity, 20.9% vs 27.6% (OR 0.88, 95%CI 0.64-1.21) and resulted in better mortality, 4.2% vs 4.9% (OR 0.51, 95%CI 0.30-0.86), as compared to the open approach. Overall, the rate of biliary leakage was likely similar, 10.6% versus 11.7% (OR 0.83, 95%CI 0.52-0.77).
This systematic review of non-randomised comparative studies suggests that MILS for PHC and IHC may result in a similar safety profile with benefits in patient recovery and oncological outcomes as compared to OLS. Prospective comparative studies, especially including robotic MILS, are warranted.
肝门部胆管癌（PHC）和肝内胆管癌（IHC）的微创肝脏手术（MILS）应用仍然有限，且缺乏仅包含MILS与开放手术对比研究的系统评价。本系统评价和荟萃分析旨在评估微创外科手术治疗肝门部和肝内胆管癌患者的安全性和有效性。
在PubMed、Embase和Cochrane数据库中进行系统评价，纳入至少5例接受MILS治疗的PHC和IHC患者与接受开放性肝脏手术患者对比的原始研究。荟萃分析纳入发病率和死亡率的主要结局。次要结局包括术后结局、复发、无病生存期和切缘。
总体上，纳入了37项比较性非随机研究，共4863例患者，其中PHC占24%，IHC占76%。21项研究进行了倾向评分匹配。总共分析了2106例腹腔镜手术、75例机器人手术和2662例开放手术。中转率中位数为11.5%[四分位间距10.0 - 12.5]。MILS可能导致主要并发症发生率降低，分别为13.3%和18.8%（比值比0.75，95%置信区间0.62 - 0.90），死亡率降低，分别为3.0%和4.5%（比值比0.69，95%置信区间0.49 - 0.97），住院时间缩短，分别为8.0天和10.9天（平均差 -2.1，95%置信区间 -2.8 - -1.5）。在倾向评分匹配队列中，MILS导致R0切除率更高，分别为90.4%和81.4%（比值比1.40，95%置信区间1.13 - 1.74），3年无病生存率更高（49.9%和38.5%，风险比3.2，95%置信区间3.1 - 3.3）。在1180例行肝空肠吻合术的患者亚组中（498例腹腔镜手术、65例机器人手术、617例开放手术），与开放手术相比，MILS仍与较低的主要并发症发生率相关，分别为20.9%和27.6%（比值比0.88，95%置信区间0.64 - 1.21），且死亡率更低，分别为4.2%和4.9%（比值比0.51，95%置信区间0.30 - 0.86）。总体而言，胆漏发生率可能相似，分别为10.6%和11.7%（比值比0.83，95%置信区间0.52 - 0.77）。
这项对非随机比较研究的系统评价表明，与开放手术相比，PHC和IHC的MILS可能具有相似的安全性，且在患者恢复和肿瘤学结局方面具有优势。有必要开展前瞻性比较研究，特别是包括机器人MILS的研究。
