Diagnostic accuracy of staging laparoscopy for detecting metastasized or locally advanced perihilar cholangiocarcinoma: a systematic review and meta-analysis

Abstract

BackgroundDespite extensive preoperative staging, still almost half of patients with potentially resectable perihilar cholangiocarcinoma (PHC) have locally advanced or metastasized disease upon exploratory laparotomy. The value of routine staging laparoscopy (SL) in these patients remains unclear with varying results reported in the literature. The aim of the present systematic review was to provide an overview of studies on SL in PHC and to define its current role in preoperative staging.MethodsA systematic review and meta-analysis were performed in PubMed and EMBASE regarding studies providing data on the diagnostic accuracy of SL in PHC. Primary outcome measures were the overall yield and sensitivity to detect unresectable disease. Secondary outcomes were the yield and sensitivity for recent studies (after 2010) and large study cohorts (≥100 patients) and specific (metastatic) lesions. Methodological quality of studies was assessed with the Quality Assessment of Diagnostic Accuracy Studies tool.ResultsFrom 173 records, 12 studies including 832 patients met the inclusion criteria. The yield of SL in PHC varied from 6.4 to 45.0 % with a pooled yield of 24.4 % [95 % confidence interval (CI) 16.4–33.4]. Sensitivity to detect unresectable disease ranged from 31.6 to 75 % with a pooled sensitivity of 52.2 % (95 % CI 47.1–57.2). Sensitivity was highest for peritoneal metastases (80.7 %, 95 % CI 70.9–88.3). Subgroup analysis revealed that the yield and sensitivity tended to be lower for studies after 2010. Considerable heterogeneity was detected among the studies.ConclusionsThe results of the pooled analyses suggest that one in four patients with potentially resectable PHC benefits from SL. Given considerable heterogeneity, a trend to lower yield in more recent studies and further improvement of preoperative imaging over time, the routine use of SL seems discouraging. Studies that identify predictors of unresectability, that enable selection of patients who will benefit the most from this procedure, are needed.Electronic supplementary materialThe online version of this article (doi:10.1007/s00464-016-4788-y) contains supplementary material, which is available to authorized users.

Modern work-up and extended resection in perihilar cholangiocarcinoma: the AMC experience

“…Up to 65–80% of patients have initially unresectable disease due to extensive hepatic artery and/or portal vein infiltration by tumor or distant metastases at time of presentation [ 10 – 13 ]. Of all patients who in time undergo a laparotomy, 40–70% ultimately have resectable disease [ 14 – 16 ]. Patients face many obstacles during diagnosis and work-up for extended resection.…”

“…There are many factors associated with resectability, prognosis and prediction of long and short-term survival after resection of PHC [ 15 , 76 – 79 ] . The most commonly used staging systems include the American Joint Committee on Cancer (AJCC) staging system with incorporated TNM classification, the Bismuth-Corlette system, the Blumgart T-staging system (MSKCC classification) and a classification recently proposed by the International Cholangiocarcinoma Group for the staging of PHC [ 14 , 15 , 20 , 77 , 79 – 81 ]. The AJCC staging system is based on pathology assessment of the resection specimen and is mainly used postoperatively as a prognostic tool.…”

Development of a Risk Score to Predict Detection of Metastasized or Locally Advanced Perihilar Cholangiocarcinoma at Staging Laparoscopy

“…LUS may theoretically be useful in detecting non-superficial liver metastases or vascular involvement, but obtaining histological evidence in the latter case might be difficult without exploration of the liver hilum. Unfortunately, limited data on the additional value of LUS are available from other studies in the literature 4. In only two of six studies, the diagnostic yield of SL was increased with the use of LUS, mainly due to the identification of locally advanced tumors 16,19…”

“…Staging laparoscopy (SL) in addition to imaging prior to exploratory laparotomy may detect small liver metastases or peritoneal metastases, thereby avoiding unnecessary laparotomy. However, the true additional diagnostic value of this procedure remains unclear, with varying results reported in the literature 4. Currently, the routine use of SL in preoperative staging of PHC is being questioned as the majority of studies from recent years have shown a diagnostic yield below 20 % and a sensitivity to detect unresectable disease lower than 60 % 5–9…”

Optimal perioperative care in peri-hilar cholangiocarcinoma resection

“…Coelen et al. addressed this issue in a pooled meta-analysis of 12 studies published in 2016, suggesting that 25% of patients with potentially resectable pCCA benefit from staging laparoscopy with the highest sensitivity for peritoneal metastases [ 28 ]. They suggest that with further improvement of radiological techniques through time, it may be possible to identify patients who will benefit most from laparoscopy.…”