| Background Peri-hilar cholangiocarcinoma(pCCA)refers to cholangiocarcinoma originating between the hepatic duct above the opening of the gallbladder duct and the initiation of the left and right secondary hepatic ducts.Due to the special location of Peri-hilar cholangiocarcinoma,it is easy to invade the portal vein and hepatic artery,and also easy to cause peripheral lymph node metastasis and nerve invasion,with a high degree of malignancy.At present,radical surgery is the only chance of cure and long-term survival for patients.Bismuth-Corlette classification is broadly used for preoperative assessment of surgical planning and the predominant side of tumor location mostly determines surgical strategy.For example,right-sided hepatectomy(RH)and left-sided hepatectomy(LH)are mostly accepted as surgical choice for Bismuth type Ⅲa and Ⅲb pCCA,respectively.But for Bismuth type Ⅰ/Ⅱ/Ⅳ tumors,the choice between RH and LH becomes more complicated and controversial,especially when tumors invade to a similar level of both sides of bile duct.Traditionally,more surgeons prefer RH to LH as surgical strategy for pCCA treatment because RH possesses some anatomical advantages over LH for achieving more radical resection,but it increases the possibility of post-hepatectomy liver failure(PHLF)and mortality.There were some studies comparing LH and RH from different perspectives of view,but consensus has not yet been established.Objective This study intends to extract the basic information and prognostic information of the patients in the study by systematically searching the published literatures related to the comparison of left and right hepatectomy for hilar cholangiocarcinoma,and then to evaluate their advantages and disadvantages respectively by statistical analysis,aiming to provide evidence-based strategy on clinical decision making for surgically resectable patients.Methods The Medline,PubMed,Web of Science,Scopus,Embase databases were searched for eligible studies from inception to December 2021.Furthermore,the reference lists of relevant literatures were manually cross searched to ensure that all eligible studies were included.After eliminating duplicates,read titles and abstracts.Final studies that met the inclusion and exclusion criteria were identified by reading full text after above steps.Standardized Excel sheets were used to extract relevant information from each study.Comparisons of OS and DFS were conducted by using hazard ratio(HR)with 95%CI(95%confidence intervals).If HR were not provided by the original studies,they were extracted from Kaplan-Meier curves by using Engauge Digitizer(version 10.8)or calculated according to the method described by Tierney.Continuous variables were expressed as mean ±standard deviation(SD),and data were transformed if the original study provided only median and interquartile ranges.Dichotomous variables were described by using the odds ratios(OR)with 95%CI.Heterogeneities between each study were assessed using a chi-square(χ2)Q test.Fixed-effects model was used when heterogeneity was low(I2<50%),otherwise random-effects model was used(I2≥50%).In addition,sources of heterogeneity were attempted to be identified via subgroup analyses and metaregressions.The publication bias was assessed by Egger’s test and plot funnel.The result analysis of the main outcome indicators was expressed in the form of forest map and table,and the difference was considered to be statistically significant when P<0.05.Results Through rigorous screening and careful reading of the relevant literatures in this field,total 14 cohort studies were included in the meta-analysis,including 1072 patients of 447 LH cases and 625 RH cases.The fixed-effects model was used and pooled HR revealed that there was no significant difference between LH and RH in OS(HR=1.03,95%CI 0.86-1.23,I2=30.3%,P=0.73)and DFS(HR=1.12,95%CI 0.90-1.39,I2=0%,P=0.31).The rate of preoperative portal vein embolization(PVE)was higher in RH group(RR=0.07,95%CI 0.04-0.12,I2=0%,P<0.01).RH group was associated with higher rate of overall complications(RR=0.82,95%CI 0.71-0.96,I2=13.92%,P=0.01),PHLF(RR=0.26,95%CI 0.12-0.56,I2=0%,P<0.01)and postoperative mortality(RR=0.42,95%CI 0.23 0.75,I2=0%,P<0.01).LH was associated with higher frequency of arterial resection/reconstruction(RR=4.20,95%CI 2.21-7.95,I2=46.75%,P<0.01),longer operation time(WMD=31.65,95%CI 3.77-59.52,P=0.03)ans postoperative bile leakage(RR=1.91,95%CI 1.17-3.11,I2=0%,P=0.01).Preoperative biliary drainage(RR=0.91,95%CI 0.81-1.02,I2=0%,P=0.10),R0 resection rate(RR=0.95,95%CI 0.88-1.02,I2=0%,P=0.12),portal vein resection and reconstruction(RR=1.08,95%CI 0.79-1.48,I2=39.1%,P=0.64),intraoperative blood loss(WMD=15.10,95%CI 85.62-115.82,I2=32.1%,P=0.77)and intraoperative blood transfusion rate(RR=1.16,95%CI 0.99-1.37,I2=0%,P=0.07)showed no significant difference.Conclusion1.Although LH is not inferior to RH in DFS and OS,it requires more arterial reconstruction which is technically demanding and should be performed by experienced surgeons.2.Selectin of surgical strategy between LH and RH should be based on not only tumor location(Bismuth classification)but also vascular involvement and FLR and flexible choice of hepatectomy is currently the most desirable surgical decision mode for hilar cholangiocarcinoma. |
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