Diagnostic cholangioscopy for surgical planning of extrahepatic cholangiocarcinoma

The recent clinical outcomes of multi-regimen chemotherapy included prolonged survival and a high rate of conversion to surgery in Asian patients with advanced biliary tract cancer. The ability of single-operator cholangioscopy (SOC) to detect and stage extrahepatic cholangiocarcinoma (CCC) in intraductal lesions is becoming more important in determining the extent of surgery. The aim of this study was to evaluate the role of SOC in surgical planning for extrahepatic CCC. We reviewed the consecutive data of patients who received nab-paclitaxel plus gemcitabine-cisplatin for the management of extrahepatic CCC and underwent preoperative evaluations between June 2020 and August 2022. SOC was performed to determine the precise extent of the disease in patients with a good response to chemotherapy who were considering surgical treatment. Among the 38 patients included, 30 (79%) were diagnosed with perihilar CCC, six (16%) with distal CCC, and two (5%) with intraductal papillary neoplasm of the bile duct. Intraductal evaluation with SOC altered disease extent defined by previous imaging findings in 14 (37%) patients. In those patients, five (36%) were changed to less extensive surgery, four (29%) to conversion surgery, four (29%) avoided surgery, and one (7%) was changed to more extensive surgery. Among the 38 included patients, 27 (71%) underwent surgery, and the accuracy of the visual impressions was 93%, as confirmed by the surgical pathology report. In conclusion, SOC examination of patients with potentially resectable extrahepatic CCC was more precise than conventional diagnostic evaluations and could help in planning surgical options.