Dear Editor,

The role of minimally invasive surgery is confirmed by previous studies. Nowadays the mini-surgery technique is applied for several medical disorders. Also it could be applied cancer treatment; the technique can also be applied. Minimally invasive surgery is usually applied for the early stage of cancer and there is high incidence of success rate of the surgery. The technique also reduced the need for long term post-operative hospitalization (1). Here, the authors discussed about the use of minimally invasive surgery in cholangiocarcinoma in our setting, Indochina where the extremely high incidence of this deadly biliary tract caner can be seen.

The main problem for management of cholangiocarcinoma in Indochina is the late presentation of the case to the physicians. Patients usually have advanced disease and the surgical management is extremely hard (2). In fact, the use of minimally invasive surgery in cholangiocarcinoma is used in some other medical centers in other regions. The recent publication from Italy noted that “Minimally invasive surgery seems feasible and safe especially for intrahepatic cholangiocarcinoma (3)”. However cases in Levi Sandri et al. study, that report covers the patients with early stage with intrahepatic cholangiocarcinoma. Which is different from cases in Indochina which are usually advanced in stage.

In Thailand, a country in Indochina, there are some reports on using minimally invasive surgery technique for management of cholangiocarcinoma. The aim is usually palliative treatment and the hilar cholangiocarcinoma is the main type of cancer for mini-surgical management (4). The endocscopic surgery is proved effective for this purpose (4). The success drainage for reliving of the hyperbilirubinemia in patients with advanced disease is the main advantage of the technique (5). Recently, Panpimanmas and Ratanachu-eket al. reported the first trial on “endoscopic ultrasound-guided hepaticogastrostomy for hilar cholangiocarcinoma” and showed that “It can improve the palliative treatment in hilar lesions because it’s internal drainage and far from tumor site that promote fast recovery (6).” According to this study, this technique is feasible and safe comparing to standard surgery. It was finally concluded that “Endoscopic-ultrasound-guided hepaticogastrostomy is safe and can be a good palliative option for advanced malignant biliary obstruction because it drains internally and is remote from the tumor site, promoting a long patency period of prosthesis and better quality of life (7).” This observation is concordant with the report from other centers (8, 9).

Based on the case of minimally invasive surgery for management of cholangiocarcinoma in Thailand, it could be concluded that the minimally invasive surgery still plays important role in management of cancerous patients with extremely advanced disease. The main role of the minimally invasive surgery is the management of the biliary obstruction due to non-removal tumor from basic traditional approach. Comparing to traditional approach, minimally invasive surgery can provide a less harmful surgery with a comparable result in palliation of the obstructive jaundice.