Curative-intent limited resection compared to extensive hepatectomy in patients with hilar cholangiocarcinoma: a systematic review and meta-analysis

Background: Curative-intent surgery for hilar cholangiocarcinoma (HCCA) comprises bile duct resection (BDR) alone, BDR combined with limited-volume hepatectomy (LVH) or extensive hepatectomy (EH). Consensus need to be reached regarding the optimal treatment modalities. We aimed to comparatively evaluate the postoperative outcomes of limited resection versus EH. Materials and Methods: This review adhered to the PRISMA and AMSTAR guidelines. A systematic literature search was performed in PubMed and Web of science for studies published up to June 18, 2025. All study designs (except case reports, comments, editorials, and reviews), that investigated postoperative outcomes in adults undergoing curative surgery for HCCA were considered, without language restrictions. Results: A total of 92 of the 4353 articles were analyzed. Compared with limited resection, EH was associated with higher rates of overall morbidity (56.5% vs. 39.3%; OR 1.89, 95% CI 1.62–2.19; P < 0.00001), major morbidity (37.3% vs. 16.4%; OR 2.35, 95% CI 1.78–3.10; P < 0.00001), and mortality (8.8% vs. 5.0%; OR 2.09, 95% CI 1.58–2.77; P < 0.00001). However, EH was also associated with lower rate of positive surgical margin (22.3% vs. 40.3%; OR 0.44, 95% CI 0.38–0.50; P < 0.00001), improved overall survival (HR 0.69, 95% CI 0.56–0.86; P = 0.0008), and a higher 5-year survival rate (30.5% vs. 20.7%; OR 1.48, 95% CI 1.24–1.76; P < 0.0001). Subgroup analysis comparing EH and LVH indicated that LVH reduced overall morbidity (37.3% vs. 59.1%; OR 0.69, 95% CI 0.52–0.91; P = 0.008) and major morbidity (25% vs. 36.7%; OR 0.67, 95% CI 0.45–1.00; P = 0.05). Although, the positive surgical margin rate was higher in the LVH group (21.9% vs. 19.7%; OR 1.38, 95% CI 1.03–1.85; P = 0.03), there were no significant differences in overall survival (HR 0.78, 95% CI 0.49–1.23; P = 0.29) or 5-year survival rate (29.5% vs. 31.5%; OR 0.88, 95% CI 0.62–1.24; P = 0.45), compared with EH. Conclusion: BDR alone is an insufficient curative procedure for HCCA, and should be applied cautiously. LVH represents a viable alternative to EH, particularly in patients with inadequate future liver remnant.