LAUSR

Simple Summary Cancers can arise from the liver bile duct system and gallbladder, known as cholangiocarcinomas and gallbladder cancers. When surgery is possible to remove the cancer, removing the lymph nodes that provide drainage (the portal lymph nodes) is important for determining the correct stage and providing important prognostic information. However, removal of these lymph nodes can be technically challenging for surgeons. The goal of this study was to evaluate postoperative outcomes after a reproducible approach to surgical removal of these lymph nodes. A stepwise, illustrated description of the technique is provided. Typically, surgeons aim to remove at least six lymph nodes when performing this operation. However, it was found that this does not always occur despite best efforts. Fewer lymph nodes were removed in older patients, which might be related to biology. Removal of the lymph nodes added time to surgery when compared to patients who did not have portal lymph nodes removed for other reasons, but did not result in worse outcomes for patients. Abstract Background: Portal lymphadenectomy (PLND) is the current standard for oncologic resection of biliary tract cancers (BTCs). However, published data show it is performed infrequently and often yields less than the recommended 6 lymph nodes. We sought to identify yield and outcomes using a Clockwise Anterior-to-Posterior technique with Double Isolation of critical structures (CAP-DI) for PLND. Methods: Consecutive patients undergoing complete PLND for BTCs using CAP-DI technique were identified (2015–2021). Lymph node (LN) yield and predictors of LN count were examined. Secondary outcomes included intraoperative and postoperative outcomes, which were compared to patients having hepatectomy without PLND. Results: In total, 534 patients were included; 71 with complete PLND (36 gallbladder cancers, 24 intrahepatic cholangiocarcinomas, 11 perihilar cholangiocarcinomas) and 463 in the control group. The median PLND yield was 5 (IQR 3–8; range 0–17) and 46% had at least 6 nodes retrieved. Older age was associated with lower likelihood of ≥6 node PLND yield (p = 0.032), which remained significant in bivariate analyses with other covariates (p < 0.05). After adjustment for operative factors, performance of complete PLND was independently associated with longer operative time (+46.4 min, p = 0.001), but no differences were observed in intraoperative or postoperative outcomes compared to the control group (p > 0.05). Conclusions: Yield following PLND frequently falls below the recommended minimum threshold of 6 nodes despite a standardized stepwise approach to complete clearance. Older age may be weakly associated with lower PLND yield. While all efforts should be made for complete node retrieval, failure to obtain 6 nodes may be an unrealistic metric of surgical quality.