Intraoperative irreversible electroporation for margin accentuation in locally advanced intrahepatic cholangiocarcinoma: a case series.

Introduction: The incidence of intrahepatic cholangiocarcinoma (iCCA) is increasing worldwide and remains associated with a poor prognosis. Surgical resection is the only potentially curative treatment; however, only a minority of patients are eligible due to advanced disease and vascular involvement. Irreversible electroporation (IRE) is a non-thermal ablative modality that enables tissue treatment while preserving vascular structures. This study aimed to evaluate the feasibility, safety, and preliminary oncologic outcomes of intraoperative IRE as an adjunct for margin accentuation in locally advanced iCCA involving critical vascular structures. Methods: Between 2023 and 2024, three patients with initially unresectable, centrally located mass-forming iCCA were treated at a single center. All tumors involved the hepatic vein of the future liver remnant, precluding conventional R0 resection. Patients underwent extended hepatectomy combined with intraoperative IRE applied at the tumor-hepatic vein interface, followed by vascular detachment to preserve venous outflow. Results: All procedures were completed as planned. No intraoperative complications or IRE-related postoperative adverse events were observed. Ninety-day mortality was 0%. Postoperative imaging confirmed preserved hepatic vein patency in all patients. At a median follow-up of 18 months (range 15-27), no local recurrence at the vascular interface was detected. One patient with initially multifocal disease developed a solitary intrahepatic recurrence at 17 months, which was successfully treated with local ablation. All patients were alive at last follow-up. Conclusions: Intraoperative IRE for margin accentuation appears to be a feasible and safe adjunct to extended hepatectomy in selected patients with locally advanced iCCA involving the hepatic vein of the future liver remnant. This anatomy-preserving strategy may expand surgical indications by enabling radical resection in cases otherwise deemed unresectable. Further studies are required to validate its oncologic benefit.