Meta-Analysis
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Oncol. Nov 15, 2023; 15(11): 2017-2032
Published online Nov 15, 2023. doi: 10.4251/wjgo.v15.i11.2017
Role of routine lymph node dissection alongside resection of intrahepatic cholangiocarcinoma: Systematic review and meta-analysis
Mo Atif, Aditya Borakati, Vasileios K Mavroeidis
Mo Atif, Department of Colorectal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, United Kingdom
Aditya Borakati, Department of HPB and Liver Transplantation Surgery, Royal Free Hospital NHS Foundation Trust, London NW3 2QG, United Kingdom
Vasileios K Mavroeidis, Department of HPB Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol Royal Infirmary, Bristol BS2 8HW, United Kingdom
Vasileios K Mavroeidis, Department of Academic Surgery, Royal Marsden NHS Foundation Trust, London SW3 6JJ, United Kingdom
Author contributions: Atif M and Borakati A contributed equally to this work; Atif M and Borakati A did the literature search, acquisition of data, analysis and drafted the original manuscript; Mavroeidis VK conceptualised and supervised the study, and made critical revisions; all authors designed the study, interpreted the data, prepared the final draft and approved the final version.
Conflict-of-interest statement: The authors declare no conflict of interests for this article.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Vasileios K Mavroeidis, MD, MSc, FRCS, FACS, FICS, MFSTEd, MICR, Surgeon, Department of HPB Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol Royal Infirmary, Upper Maudlin St, Bristol BS2 8HW, United Kingdom. vasileios.mavroeidis@nhs.net
Received: August 10, 2023
Peer-review started: August 10, 2023
First decision: August 30, 2023
Revised: September 14, 2023
Accepted: October 23, 2023
Article in press: October 23, 2023
Published online: November 15, 2023
Processing time: 96 Days and 20 Hours
Abstract
BACKGROUND

The global incidence of intrahepatic cholangiocarcinoma (ICCA) is soaring. Due to often delayed presentation, only a narrow spectrum of the disease is usually surgically resectable. To more accurately stage the disease, reduce recurrence, and improve overall survival, surgical teams are increasingly performing intraoperative lymph node dissection (LND) as well. This procedure has its associated morbidity, while there is no consensus or formal guidelines on its role in this setting. Hence, there is a need to better delineate the evidence for performing LND alongside surgical resection of the ICCA.

AIM

To perform a systematic review and meta-analysis on the role of LND in improving prognostication and survival post-resection of ICCA.

METHODS

We performed a systematic literature search using Pubmed, Medline, Embase, and the Cochrane Library, for all studies involving LND, ICCA, and surgical resection using several keywords, Medical Subject Headings (MeSH) tags, and appropriate synonyms. All clinical studies comparing curative intent resection of ICCA with LND vs resection without LND were included, while single-arm case series, studies with insufficient data, and duplicates were excluded. We included all English-language studies from the different academic databases up till early December 2022. The primary outcome measures were set for overall survival (OS) and disease-free survival (DFS).

RESULTS

This systematic review and meta-analysis included 15 studies that fulfilled the selection criteria comprising 11413 patients with surgically-resectable ICCA, of whom 6424 (56.3%) underwent hepatectomy with LND while the remainder underwent hepatectomy only. In patients who underwent LND, on average, 27.7% of the resected lymph nodes were positive for metastatic disease. Overall, the results showed that performing LND did not significantly improve OS or DFS. However, the effect of LND on OS showed a degree of variability by geographical region, in Eastern and Western countries. As LND is increasingly being performed, further time-based analysis was undertaken to identify time-dependent changes in the role of LND. An increasing adoption of LND was not associated with improved OS. Furthermore, no roles were identified for neoadjuvant/adjuvant chemotherapy or increasing lymph node retrieval in improving OS either.

CONCLUSION

LND might aid in staging, prognosticating, and deciding further management of resected ICCA, but does not improve OS and DFS and is unsuitable for high-risk patients unlikely to benefit from further treatments.

Keywords: Cholangiocarcinoma; Periductal-infiltrating; Mass-forming; Lymphadenectomy; Lymph node metastasis; Hepatectomy

Core Tip: The overall survival (OS) from surgically resectable intrahepatic cholangiocarcinoma remains poor. Lymph node dissection is increasingly being performed in the setting of hepatic resection with the aims of improving patient outcomes such as OS, minimising recurrence, as well as for accurate staging. However, no consensus exists in the literature regarding its use for these purposes. This systematic review and meta-analysis of hepatic resection with and without lymph node dissection for surgically resectable intrahepatic cholangiocarcinoma was performed with the primary outcome measures of OS and disease-free survival.