Minimally invasive pancreaticoduodenectomy reduces blood loss and hospital stay in distal cholangiocarcinoma surgeryMinimally invasive surgery shows benefits for certain bile duct cancer

BACKGROUND: Distal cholangiocarcinoma (dCCA) is a rare but aggressive biliary malignancy arising from the distal bile duct with significant clinical burden. Pancreaticoduodenectomy (minimally invasive or open) remains the only potentially curative treatment for dCCA. However, the comparative safety and oncologic adequacy of minimally invasive versus open pancreaticoduodenectomy remains unclear, creating an evidence gap that this systematic review addresses. OBJECTIVE: This systematic review and meta-analysis aimed to compare perioperative outcomes and oncologic effectiveness of MIPD versus OPD in patients undergoing surgery for distal cholangiocarcinoma. METHODS: A systematic literature search of PubMed, Embase, Cochrane Library, and Science Direct was conducted through April 2025 in accordance with PRISMA guidelines. Eligible studies included cohort studies, randomized controlled trials, and case-control studies comparing MIPD (laparoscopic or robotic) with OPD in dCCA. Data regarding operative parameters, oncologic outcomes, perioperative morbidity, and mortality were extracted. Meta-analysis was performed using Review Manager 5.4, applying fixed- or random-effects models based on heterogeneity. RESULTS: Seven retrospective cohort studies comprising 1,803 patients (775 MIPD vs. 1,028 OPD) were included. MIPD was associated with significantly lower blood loss (WMD - 100.86 mL, 95% CI - 107.27 to - 94.46; I² = 90%; p < 0.001) and shorter hospital stay (WMD - 2.46 days, 95% CI - 4.08 to - 0.84; I² = 89%; p = 0.003), but longer operative time (WMD 52.60 min, 95% CI 16.82 to 88.39; I² = 99%; p = 0.004). There was no significant difference in major complications (Clavien-Dindo ≥ III) (OR 0.97, 95% CI 0.74-1.28; p = 0.85) or postoperative mortality (OR 0.46, 95% CI 0.16-1.33; I² = 56%; p = 0.15) between groups. Importantly, long-term oncologic outcomes were also comparable between groups, with no significant differences observed in overall survival (HR 0.90, 95% CI 0.77-1.05; p = 0.19) or disease-free survival (HR 0.98, 95% CI 0.83-1.16; p = 0.83). No survival disadvantage was demonstrated for MIPD compared with OPD. CONCLUSION: MIPD appears to be a safe and feasible alternative to OPD for selected patients with distal cholangiocarcinoma, offering perioperative benefits without compromising oncologic outcomes. Importantly, available evidence also demonstrates no compromise in long-term oncologic outcomes, with comparable overall and disease-free survival between MIPD and OPD. However, given the rarity of dCCA, stand-alone randomized controlled trials are unlikely to be feasible. Future evidence should therefore focus on stratifying dCCA patients within ongoing or future multicenter trials of minimally invasive pancreaticoduodenectomy for periampullary malignancies, as well as prospective international registry-based studies with mandatory reporting of histological subtypes to generate high-quality, generalizable evidence.