Update to the role of staging laparoscopy in the assessment of resectability of perihilar cholangiocarcinoma: have improvements in cross-sectional and functional imaging rendered it redundant?

Background: Perihilar cholangiocarcinoma has poor prognosis. Accurate staging is paramount in stratifying patients to appropriate treatment: curative surgery or palliative systemic anti-cancer therapy. Conventional CT and MRI are insufficiently sensitive at identifying peritoneal or liver metastases. Since 2020, [18F]fluorodeoxyglucose positron emission tomography-computerised tomography (FDG PET-CT) has been incorporated into staging, prompting reassessment of staging laparoscopy's role in determining resectability.

Methods: This retrospective study reviewed patients referred with suspected perihilar cholangiocarcinoma to a UK hepatobiliary centre between 2020 and 2024 (n = 304). Those with potentially resectable disease on conventional CT and MRI were compared to a matched 2016-2019 cohort (n = 57).

Results: Between 2020 and 2024, CT and MRI identified inoperable disease in 248/304 patients. FDG PET-CT further excluded 16/56 patients. Staging laparoscopy in 40 patients excluded 5. Among 35 proceeding to laparotomy, 33 completed curative-intent resection. In 2016-2019, all 57 underwent staging laparoscopy, excluding 9. Of 48 proceeding to laparotomy, 40 completed resection.

Conclusions: Advances in cross-sectional imaging, including FDG PET-CT, have improved radiological staging. However, at 1-in-8, the diagnostic yield of staging laparoscopy remains high, justifying its continued role in evaluating resectability.