Laparoscopic resection vs. open liver resection for peripheral hepatocellular carcinoma in patients with chronic liver disease: a case-matched study. Surg Endosc. 2011;25:3668-3677. [PMID: 21688080 DOI: 10.1007/s00464-011-1775-1]

Meta-analysis of laparoscopic vs open liver resection for hepatocellular carcinoma

Laparoscopic liver resections (LLR) are widely accepted as safe and effective procedures for the management of hepatocellular carcinoma (HCC) in the hands of experienced surgeons. The efficacy and extent of benefits of pure as well as hand-assisted laparoscopic and laparoscopy-assisted liver resection over open liver resection (OLR) have been investigated by numerous studies during the last 10 years. The aim of our meta-analysis is to investigate the effect of LLR in short- and long-term outcomes compared to OLR in patients operated for HCC. A total of 5203 patients from forty-four studies were included in our meta-analysis reporting for short- and long-term results for both LLR and OLR for HCC. Among them, 1830 underwent pure laparoscopic hepatectomy, 282 underwent pure laparoscopic or hand-assisted laparoscopic or laparoscopy-assisted hepatectomy, and 3091 were operated through open approach. LLRs were found to be significantly associated with lower blood loss, need for blood transfusion, successful achievement of R0 resection as well as wider resection margin, shorter hospital stay, lower morbidity and 30-day mortality rates. Operative time, tumor recurrence, 1-, 3-, and 5-year overall survival as well as 1-, 3-, and 5-year disease-free survival were not found different between the groups. This meta-analysis clearly demonstrates the superiority of laparoscopic resection over the open approach for patients with small HCC.

The Clinical Significance of Alpha-Fetoprotein mRNAs in Patients with Hepatocellular Carcinoma

BACKGROUND/AIMS

Alpha-fetoprotein (AFP) mRNA-expressing cells are candidates for circulating tumor cells in hepatocellular carcinoma. We analyzed portal vein blood, peripheral blood, and peritoneal lavage samples to detect the presence of AFP mRNA-expressing cells, and explored their relationship with metastasis.

METHODS

We measured the AFP mRNA expression in 112 sets of portal vein and peripheral blood samples and 61 peritoneal lavage samples that had been obtained during surgery. We estimated the change in the positive ratio of patients with AFP mRNA, the associated background factors, and the rate of recurrence.

RESULTS

The change in AFP mRNA positivity in the peripheral blood specimens was remarkable, while that in the portal vein blood and peritoneal lavage samples was similar during hepatectomy. Tumor location was the only factor associated with AFP mRNA positivity. The rate of recurrence was higher in the patients who were positive for AFP mRNA than in those who were negative 9-24 months after hepatectomy. During this limited period, the recurrence rate in the AFP mRNA-positive cases was significantly higher than that in the AFP mRNA-negative cases (p = 0.0472). Postoperative AFP mRNA positivity was not related to very early recurrence (0-9 months) or multicentric liver carcinogenesis (>24 months).

CONCLUSION

AFP mRNA positivity in the peripheral blood was elevated after hepatectomy, and the elevation depended on the tumor location. AFP mRNA positivity might contribute to recurrence-free survival 9-24 months after hepatectomy.

Laparoscopic Liver Resection of Hepatocellular Carcinoma with a Tumor Size Larger Than 5 cm: Review of 45 Cases in a Tertiary Institution

INTRODUCTION

Although laparoscopic liver resection (LLR) has developed rapidly, its usefulness for the treatment of large tumors is less clear, due to concerns about compromising oncological principles and patient safety. The purpose of this study was to explore the feasibility and safety of LLR for the treatment of hepatocellular carcinoma (HCC) with a tumor size larger than 5 cm.

PATIENTS AND METHODS

From January 2007 to December 2014, we performed LLR in 45 patients with HCC with a tumor size ≥5 cm. Perioperative outcome, tumor recurrence, and overall patient survival were analyzed.

RESULTS

Median age was 60 years (interquartile range [IQR] 52-68) and 64.4% (29/45) were male. Seven patients (15.6%) had larger than 10 cm of HCC. No operative deaths occurred and six of the laparoscopic procedures were converted to open resection (conversion rate 13.3%). Median operation time was 365 minutes (IQR 277-443) and median estimated blood loss (EBL) was 400.0 mL (IQR 275-600). There was no R1 or R2 resection and median resection margin was 19.0 mm (IQR 8.0-33.0). Complications above Clavien-Dindo classification grade III occurred in four patients (8.9%). The median overall follow-up time was 10.7 month (range 1.1-62.1). One-year recurrence free survival (RFS) and overall survival (OS) were 86.0% and 95.5%, and 3-year RFS and OS were 70.7% and 86.0%.

CONCLUSION

LLR appears safe and feasible in patients with HCC with a tumor size larger than 5 cm. Expansion of indication for LLR in patients with HCC may be considered.

Totally laparoscopic anatomical liver resection for centrally located tumors: A single center experience

Laparoscopic major hepatectomy is a common procedure that has been reported frequently; however, laparoscopic resection of centrally located tumors involving segments 4, 5, and 8 remains a technically difficult procedure because it requires 2 transection planes and dissection of numerous branches of the hepatic vein and glissonean capsule compared to hemi-hepatectomy. Here, we present 7 cases of totally laparoscopic right anterior sectionectomy (Lap-RAS) and 3 cases of totally laparoscopic central bisectionectomy (Lap-CBS).Between May 2013 and January 2015, 10 totally laparoscopic anatomical resections of centrally located tumors were performed in our institution. The median age of the patients was 54.2 (38-72) years and the median ICG-R15 was 10.4 (3.9-17.4). There were 8 patients with hepatocellular carcinoma (HCC) and 2 with metastatic colorectal cancer. All the HCC patients has the liver function impairment on the degree of Child-Pugh score A.The mean operation time was 330 ± 92.7 minutes with an estimated blood loss of 325 ± 234.5 mL. Only 1 patient required transfusion during surgery. Mean postoperative hospital stay was 9.5 ± 3.4 day and postop complication was reported only 1 case that has the fluid collection at the resection margin of the liver. Mean resection margin was 8.5 ± 6.1 mm and tumor size was 2.9 ± 1.9 cm.Totally lap-RAS and lap-CBS are feasible operative procedures in patients with centrally located tumor of the liver and particularly in patients with limited liver function such as those with cirrhosis.

HVPG signature: A prognostic and predictive tool in hepatocellular carcinoma

Hepatic venous pressure gradient (HVPG) measurement provides independent prognostic value in patients with cirrhosis, and the prognostic and predictive role of HVPG in hepatocellular carcinoma (HCC) also has been explored. The management of HCC is limited to the European Association for the Study of the Liver (EASL) and American Association for the Study of Liver Diseases (AASLD) guidelines that consider that HVPG≥10 mmHg to be a contraindication for hepatic resection (HR), otherwise other treatment modalities are recommended. Current studies show that a raised HVPG diagnosed directly or indirectly leads to a negative prognosis of patients with HCC and cirrhosis, but HVPG greater than 10 mmHg should not be regarded as an absolute contraindication for HR. Selecting direct or surrogate measurement of HVPG is still under debate. Only several studies reported the impact of HVPG in negative prognosis of HCC patients after liver transplantation (LT) and the value of HVPG in the prediction of HCC development, which need to be further validated.

Comparative Short-term Benefits of Laparoscopic Liver Resection: 9000 Cases and Climbing

OBJECTIVE

To perform a systematic review of worldwide literature on laparoscopic liver resections (LLR) and compare short-term outcomes against open liver resections (OLR) by meta-analyses.

SUMMARY BACKGROUND DATA

There are no updated pooled data since 2009 about the current status and short-term outcomes of LLR worldwide.

PATIENTS AND METHODS

All English language publications on LLR were screened. Descriptive worldwide data and short-term outcomes were obtained. Separate analyses were performed for minor-only and major-only resection series, and series in which minor/major resections were not differentiated. Apparent case duplications were excluded.

RESULTS

A set of 463 published manuscripts were reviewed. One hundred seventy-nine single-center series were identified that accounted for 9527 LLR cases worldwide. Minor-only, major-only, and combined major-minor series were 61, 18, and 100, respectively, including 32, 8, and 43 comparative series, respectively. Of the total 9527 LLR cases reported, 6190 (65%) were for malignancy and 3337 (35%) were for benign indications. There were 37 deaths reported (mortality rate = 0.4%). From the meta-analysis comparing case-matched LLR to OLR (N = 2900 cases), there was no increased mortality and significantly less complications, transfusions, blood loss, and hospital stay observed in LLR vs OLR.

CONCLUSIONS

This is the largest review of LLR available to date with over 9000 cases published. It confirms growing safety when performed in selected patients and by trained surgeons, and suggests that LLR may offer improved patient short-term outcomes compared with OLR. Improved levels of evidence, standardized reporting of outcomes, and assuring proper training are the next challenges of laparoscopic liver surgery.

Innovative surgical approaches for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide, with an increasing diffusion in Europe and the United States. The management of such a cancer is continuously progressing and the objective of this paper is to evaluate innovation in the surgical treatment of HCC. In this review, we will analyze the modern concept of preoperative management, the role of laparoscopic and robotic surgery, the intrao-perative use of three dimensional models and augme-nted reality, as well as the potential application of fluore-scence.

Favorable Long-Term Oncologic Outcomes of Hepatocellular Carcinoma Following Laparoscopic Liver Resection

BACKGROUND

Reports on the long-term oncologic outcomes of laparoscopic liver resection (LLR) compared to open liver resection (OLR) in patients with hepatocellular carcinoma (HCC) are rare. The aim of this study was to compare the long-term outcomes of LLR and OLR as a treatment for HCC patients.

PATIENTS AND METHODS

A total of 125 patients were included in the study (32 patients underwent LLR and 93 underwent OLR). Data were categorized according to operation methods. The primary endpoints were disease-free survival and overall survival. The secondary endpoints were surgical outcomes of LLR for HCC.

RESULTS

Capsular invasion was more frequent in the LLR group (P = .001). The median follow-up period was 48 months (1-188 month). There were no significant differences between the two groups regarding mortality and morbidity. Hospitalization days were shorter in the LLR group (P = .042). Disease-free 5-year survival of HCC was 40.9% and 47.2% in the LLR and OLR group, respectively (P = .376). Overall 5-year survival for HCC was 96.4% and 96.7% for the LLR and OLR group, respectively (P = .748).

CONCLUSION

Our long-term analysis on oncologic aspects confirms the safety of LLR compared to OLR in HCC patients.

The safety and efficacy of approaches to liver resection: a meta-analysis

Background:

The aim of this study is to compare the safety and efficacy of conventional laparotomy with those of robotic and laparoscopic approaches to hepatectomy.

Database:

Independent reviewers conducted a systematic review of publications in PubMed and Embase, with searches limited to comparative articles of laparoscopic hepatectomy with either conventional or robotic liver approaches. Outcomes included total operative time, estimated blood loss, length of hospitalization, resection margins, postoperative complications, perioperative mortality rates, and cost measures. Outcome comparisons were calculated using random-effects models to pool estimates of mean net differences or of the relative risk between group outcomes. Forty-nine articles, representing 3702 patients, comprise this analysis: 1901 (51.35%) underwent a laparoscopic approach, 1741 (47.03%) underwent an open approach, and 60 (1.62%) underwent a robotic approach. There was no difference in total operative times, surgical margins, or perioperative mortality rates among groups. Across all outcome measures, laparoscopic and robotic approaches showed no difference. As compared with the minimally invasive groups, patients undergoing laparotomy had a greater estimated blood loss (pooled mean net change, 152.0 mL; 95% confidence interval, 103.3–200.8 mL), a longer length of hospital stay (pooled mean difference, 2.22 days; 95% confidence interval, 1.78–2.66 days), and a higher total complication rate (odds ratio, 0.5; 95% confidence interval, 0.42–0.57).

Conclusion:

Minimally invasive approaches to liver resection are as safe as conventional laparotomy, affording less estimated blood loss, shorter lengths of hospitalization, lower perioperative complication rates, and equitable oncologic integrity and postoperative mortality rates. There was no proven advantage of robotic approaches compared with laparoscopic approaches.

Laparoscopic liver resection for hepatocellular carcinoma in cirrhotic patients: 10-year single-center experience

BACKGROUND

Liver resection in cirrhotic patients reported to have higher morbidity and mortality rates compared to non-cirrhotic patients. Recently, there is increased acceptance of laparoscopic approach in liver surgery. However, few reports evaluated laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) in cirrhotic patients. The aim of this study is to evaluate our experience of LLR for HCC and to compare perioperative and long-term outcomes between patients with and without liver cirrhosis (LC).

METHODS

A retrospective analysis of 232 patients who underwent LLR for HCC between 2004 and 2013 was carried out. Patients were divided into two groups according to the pathological status of their liver parenchyma, in terms of presence or absence of LC.

RESULTS

LC group had 141 patients, and non-LC group had 91 patients. There were no statistically significant differences between both groups regarding operation time, blood loss, transfusion requirements, intraoperative complications, hospital stay, and postoperative complications. Long-term oncologic outcomes were comparable between both groups regarding the recurrence rates (p = 0.067), overall survival (OS) rates (p = 0.908), and disease-free survival (DFS) rates (p = 0.197). The 1-, 3-, 5-, and 7-year OS were 91.7, 85.5, 79.4, and 70.1% in LC group, and 93.9, 86, 79.5, and 72.3% in non-LC group. The 1-, 3-,5-, and 7-year DFS were 75.3, 52.4, 42.6, and 32.7% in LC group, and 74.1, 57.6, 55.3, 50.2% in non-LC group.

CONCLUSIONS

LLR for HCC is feasible in patients with LC. Cirrhotic patients showed comparable perioperative and long-term outcomes to non-cirrhotic patients.

Laparoscopic liver resection: Experience based guidelines

Laparoscopic liver resection (LLR) has been progressively developed along the past two decades. Despite initial skepticism, improved operative results made laparoscopic approach incorporated to surgical practice and operations increased in frequency and complexity. Evidence supporting LLR comes from case-series, comparative studies and meta-analysis. Despite lack of level 1 evidence, the body of literature is stronger and existing data confirms the safety, feasibility and benefits of laparoscopic approach when compared to open resection. Indications for LLR do not differ from those for open surgery. They include benign and malignant (both primary and metastatic) tumors and living donor liver harvesting. Currently, resection of lesions located on anterolateral segments and left lateral sectionectomy are performed systematically by laparoscopy in hepatobiliary specialized centers. Resection of lesions located on posterosuperior segments (1, 4a, 7, 8) and major liver resections were shown to be feasible but remain technically demanding procedures, which should be reserved to experienced surgeons. Hand-assisted and laparoscopy-assisted procedures appeared to increase the indications of minimally invasive liver surgery and are useful strategies applied to difficult and major resections. LLR proved to be safe for malignant lesions and offers some short-term advantages over open resection. Oncological results including resection margin status and long-term survival were not inferior to open resection. At present, surgical community expects high quality studies to base the already perceived better outcomes achieved by laparoscopy in major centers’ practice. Continuous surgical training, as well as new technologies should augment the application of laparoscopic liver surgery. Future applicability of new technologies such as robot assistance and image-guided surgery is still under investigation.

A Left-Sided, Purely Laparoscopic Approach for Anatomic Caudate Hepatectomy: A Single-Center Experience

BACKGROUND

Laparoscopic caudate hepatectomy, which is a challenging procedure, has been reported sporadically. However, there is no standardized surgical technique, and the safety and feasibility of this procedure remain controversial.

MATERIALS AND METHODS

A left-sided, purely laparoscopic approach for anatomic caudate hepatectomy was used for 11 selected patients in our institution. The procedure and technique of laparoscopic caudate hepatectomy were described. Perioperative data of these patients were retrospectively reviewed.

RESULTS

The 11 cases included two subgroups: laparoscopic isolated caudate hepatectomy (n = 4) and laparoscopic combined caudate and left hemihepatectomy (n = 7). There were three major steps for anatomic caudate hepatectomy. Two conversions were required (18.2%). Two complications (Clavien Grades I and II) occurred but no deaths.

CONCLUSIONS

The left-sided, purely laparoscopic approach for anatomic caudate hepatectomy is safe and feasible in selected patients. This procedure can be performed by hepatobiliary surgeons with abundant experience in laparoscopic liver surgery.

Liver resection for hepatocellular carcinoma in patients with portal hypertension: the role of laparoscopy

Liver resection (LR) for hepatocellular carcinoma (HCC) in patients with chronic liver disease (CLD) is a major issue since patients are at risk of serious intraoperative and postoperative complications. The current EASL/AASLD guidelines recommend LR only in case of patients with stage A HCC with well-preserved liver function and consider the presence of portal hypertension (PHT) as a contraindication to surgery. Nevertheless, the literature on this topic is conflicting. Recently several studies reported that favorable outcomes can be achieved with a careful patients' selection in high volume centers. Laparoscopic LR, when performed by well-trained surgeons and with appropriate indications, proved to be a valid option for the surgical treatment of HCC on cirrhosis offering similar oncologic outcomes but a reduction in surgical related morbidities. Laparoscopic LR thanks to a reduction in the incidence of post-operative liver failure and ascites development in comparison to standard open LR could, in selected cases challenge alternative treatments in the treatment of HCC patients with preserved liver function and clinical signs of mild PHT.

Laparoscopic liver resection for hepatocellular carcinoma in patients with cirrhosis

Liver resection for patients with cirrhosis remains a challenging operation. The presence of thrombocytopenia and portal hypertension could lead to severe bleeding during hepatectomy. The enthusiasm of laparoscopic hepatectomy has been growing and many studies have reported their initial favorable results for patients with hepatocellular carcinoma (HCC). The advancement in technology, better understanding of the use of pneumoperitoneum pressure and more experience accumulated make laparoscopic liver resection for patients with cirrhosis possible. Favorable outcome may be achieved if the patients are carefully selected and carried out in high volume centers.

Laparoscopic liver resection for hepatitis B and C virus-related hepatocellular carcinoma in patients with Child B or C cirrhosis

BACKGROUND

The aim of this study was to evaluate the clinical and oncological outcomes after laparoscopic liver resection (LLR) in patients with hepatitis B and C virus-related hepatocellular carcinoma (HCC) with Child B or C cirrhosis.

METHODS

Between January 2004 and December 2013, LLR was performed in 232 patients with HCC. Of these, 141 patients also had pathologically proven cirrhosis. Sixteen patients with hepatitis B and C virus-related HCC with Child B or C cirrhosis were included in the study. Thirteen (81.3%) patients had Child B disease and three (18.8%) patients had Child C disease.

RESULTS

The median operation time was 215 min, the median estimated blood loss was 350 mL, and the median hospital stay was eight days. Three patients (18.8%) experienced complications after surgery. There was no postoperative mortality or reoperation. The mean follow-up period was 51.6 months. HCC recurred in eight (50%) patients: seven intrahepatic recurrences and one extrahepatic recurrence. The treatments for recurrence were laparoscopic reoperation in one (6.3%) patient, trans-catheter arterial chemo-embolization (TACE) in one (6.3%) patient, radiofrequency ablation (RFA) in one (6.3%) patient, and combined TACE and RFA in four (25%) patients. The five-year postoperative overall survival (OS) and disease-free survival (DFS) were 84.4% and 41.7%, respectively.

CONCLUSIONS

This study demonstrates that LLR can be safely used in patients with hepatitis B and C virus-related HCC and Child B or C cirrhosis, with acceptable survival outcomes.

Early results of liver resection using laparoscopic technique

The aim of the study was to present early outcomes of liver resection using laparoscopic technique.

MATERIAL AND METHODS

Retrospective analysis of patients who underwent liver resection using laparoscopic method was conducted. The analyzed group included 23 patients (11 women and 12 men). An average patient age was 61.3 years (37 - 83 years). Metastases of the colorectal cancer to the liver were the cause for qualification to the procedure of 15 patients, metastasis of breast cancer in 1 patient and primary liver malignancy in 5 patients. The other 2 patients were qualified to the liver resection to widen the surgical margins due to gall-bladder cancer diagnosed in the pathological assessment of the specimen resected during laparoscopic cholecystectomy, initially performed for other than oncology indications.

RESULTS

Hemihepatectomy was performed in 11 patients (9 right and 2 left), while the other 12 patients underwent minor resection procedures (5 metastasectomies, 4 nonanatomical liver resections, 1 bisegmentectomy, 2 resections of the gall-bladder fossa). An average duration of the surgical procedure was 275 minutes 65 - 600). An average size of the resected tumors was 28 mm (7 - 55 mm). In three cases conversion to laparotomy occurred, caused by excessive bleeding from the liver parenchyma. Postoperative complications were found in 4 patients (17.4%). Median hospitalization duration was 6 days (2 - 130 days). One patient (4.3%) was rehospitalized due to subhepatic abscess and required reoperation. Histopathology assessment confirmed radical resection (R0) in all patients in our group.

CONCLUSION

Laparoscopic liver resections seem to be an interesting alternative in the treatment of focal lesions in the liver.

The importance of surgical margins in primary malignancies of the liver

Resection is an important treatment modality for hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). Anatomic resection is generally preferred for HCC. When anatomic resection is not feasible, prospective data have demonstrated an improved outcome among HCC patients who have a resection with wide versus narrow surgical margins. Similarly, among patients with ICC, R1 resection has been associated with worse outcomes. In addition, margin width may also impact risk of recurrence and survival. As such, provided adequate functional liver remnant remains, anatomic resection with wide margins is recommended for HCC and ICC.

Comparative study and systematic review of laparoscopic liver resection for hepatocellular carcinoma

AIM: To compare the surgical outcomes between laparoscopic liver resection (LLR) and open liver resection (OLR) as a curative treatment in patients with hepatocellular carcinoma (HCC).

METHODS: A PubMed database search was performed systematically to identify comparative studies of LLR vs OLR for HCC from 2000 to 2014. An extensive text word search was conducted, using combinations of search headings such as “laparoscopy”, “hepatectomy”, and “hepatocellular carcinoma”. A comparative study was also performed in our institution where we analysed surgical outcomes of 152 patients who underwent liver resection between January 2005 to December 2012, of which 42 underwent laparoscopic or hand-assisted laparoscopic resection and 110 underwent open resection.

RESULTS: Analysis of our own series and a review of 17 high-quality studies showed that LLR was superior to OLR in terms of short-term outcomes, as patients in the laparoscopic arm were found to have less intraoperative blood loss, less blood transfusions, and a shorter length of hospital stay. In our own series, both LLR and OLR groups were found to have similar overall survival (OS) rates, but disease-free survival (DFS) rates were higher in the laparoscopic arm.

CONCLUSION: LLR is associated with better short-term outcomes compared to OLR as a curative treatment for HCC. Long-term oncologic outcomes with regards to OS and DFS rates were found to be comparable in both groups. LLR is hence a safe and viable option for curative resection of HCC.

Laparoscopic versus open hepatic resection for hepatocellular carcinoma: improvement in outcomes and similar cost

OBJECTIVE

To compare outcomes of laparoscopic versus open hepatic resection (OHR) exclusively for hepatocellular carcinoma in terms of morbidity and cost.

BACKGROUND

Laparoscopic hepatic resection (LHR) has become more prevalent with recent improvements in instrumentation and surgeon experience.

METHODS

A review of multicenter, prospectively collected hepatobiliary databases from three institutions was performed from 12/1990 to 12/2009. Prospective evaluation of all patients undergoing hepatectomy for hepatocellular cancer was performed.

RESULTS

A total of 354 patients who had resections for Hepatocellular carcinoma (HCC) were analyzed, 100 were performed laparoscopically. The two groups were similar in terms of demographics and comorbidities. Evaluation of outcomes showed significantly higher intraoperative estimated blood loss although postoperative transfusion rates were similar. The incidence of any complication (44 vs 44%, p = 0.23) and 90-day mortality (6 vs 6%, p = 0.8) were similar between the two groups, with a similar reoperation rate (4.0 vs. 2.4%; p = 0.9). Using Cox regression analysis, the laparoscopic approach had no effect on disease-free interval (OR 1.4, CI 0.31-6.3, p = 0.66) or overall survival (HR 1.2, CI 0.59-2.5 p = 0.6). Length of stay was significantly shorter in the laparoscopic group 6.2 vs. 9.3 days (p = 0.001). Adjusted operative charges ($41 vs. $39 k, p = 0.601) and adjusted total hospital charges ($71 vs. $82 k, p = 0.368) were similar in LHR versus OHR.

CONCLUSION

Our study confirms previous literature showing comparable perioperative outcomes and recurrence. We further show comparable cost with laparoscopic versus open liver resection for HCC.

Surgical outcomes after laparoscopic or robotic liver resection in hepatocellular carcinoma: a propensity-score matched analysis with conventional open liver resection

BACKGROUND

This study was designed to compare perioperative and oncologic outcomes between minimally invasive liver resection (MILR) and conventional open liver resection (COLR) for hepatocellular carcinoma (HCC) using a propensity-score matched analysis.

METHODS

Ninety-nine patients who received MILR were matched with 198 patients treated with COLR out of 928 patients with HCC who received curative liver resection from 2002 to 2012. A multivariable logistic model based on factors related to the patient, tumor, and surgical procedure was used to estimate a propensity score.

RESULTS

The MILR group experienced significantly less intraoperative blood loss (mean: 389.55 vs 580.66 mL; P = 0.008), lower complication rates (13.1% vs 24.7%; P = 0.020), and a shorter length of hospital stay (mean: 8.40 vs 13.39 days; P < 0.001). The two groups did not differ significantly in disease-free (P = 0.701) or overall survival (P = 0.086).

CONCLUSIONS

MILR produced better perioperative and comparable oncologic outcomes than COLR for HCC. Copyright © 2015 John Wiley & Sons, Ltd.

Laparoscopic versus open liver resection for hepatocellular carcinoma: Case-matched study with propensity score matching

BACKGROUND & AIMS

Laparoscopic liver resection has gained wide acceptance and is established as a safe alternative to open liver resection. Until now, there is no prospective randomized comparative study between laparoscopic and open liver resection. Previous comparative studies reported minor resections for peripheral tumors, and enrolled small numbers of patients. Moreover, few reported the long term outcomes. The aim of this study is to compare perioperative and long term outcomes of laparoscopic versus open liver resection for hepatocellular carcinoma between two matched groups.

METHODS

389 patients underwent liver resection for hepatocellular carcinoma during the period between 2004 and 2013. To overcome selection bias, we performed 1:1 match using propensity score matching between laparoscopic and open liver resection.

RESULTS

After propensity score matching, 88 patients were included in each group. Laparoscopic group had shorter hospital stay (8 vs. 10 days, p⩽0.001), and lower postoperative morbidity (12.5% vs. 20.4%, p=0.042). The 1-, 3- and 5-year overall survivals were 91.6%, 87.5%, and 76.4%, for laparoscopic group, and were 93.1%, 87.8%, and 73.2%, for open group (p=0.944). The 1-, 3- and 5-year disease free survivals were 69.7%, 52%, and 44.2%, for laparoscopic group, and 74.7%, 49.5%, 41.2%, for open group (p=0.944).

CONCLUSIONS

Our study showed comparative perioperative and long term outcomes between both groups, providing evidence regarding the safety and efficacy of laparoscopic liver resection for hepatocellular carcinoma.

Perspective of laparoscopic liver resection for hepatocellular carcinoma

Liver resection (LR) for hepatocellular carcinoma (HCC) in patients with chronic liver disease (CLD) is associated with high risks of developing significant postoperative complications and multicentric metachronous lesions, which can result in the need for repeated treatments. Studies comparing laparoscopic procedures to open LR consistently report reduced blood loss and transfusions requirements, lower postoperative morbidity, and shorter hospital stays, with no differences in oncologic outcomes. In addition, laparoscopic LR is associated with reduced postoperative ascites and a lower incidence of liver failure for HCC patients with CLD, due to the reduced surgery-induced parenchymal injury to the residual liver and limited destruction of the collateral blood/lymphatic flow around the liver. Finally, this procedure facilitates subsequent repeat LR due to minimal adhesion formation and improved vision/manipulation between adhesions. These characteristics of laparoscopic LR may lead to an expansion of the indications for LR. This editorial is based on the review and meta-analysis presented at the 2^nd International Consensus Conference on Laparoscopic Liver Resection in Iwate, Japan, in October 2014 (Chairperson of the congress is Professor Go Wakabayashi from the Department of Surgery, Iwate Medical University School of Medicine), which is published in the Journal of Hepato-Biliary-Pancreatic Sciences.

Laparoscopic versus open major hepatectomy for hepatocellular carcinoma: a matched pair analysis

BACKGROUND

Laparoscopic major hepatectomy (LMH) for hepatocellular carcinoma (HCC) is currently perceived a complex and challenging laparoscopic procedure and is limited to a few expert teams. This study analyzed the short- and long-term outcomes of LMH for HCC compared with open hepatectomy.

METHODS

From January 2006 to May 2014, 38 patients underwent LMH for HCC (10 left and 28 right hepatectomy). They were matched and compared to 38 patients (10 left and 28 right hepatectomy) who underwent a conventional open approach. Short-term operative and postoperative outcomes as well as long-term outcomes, including disease-free survival and overall survival rates, were evaluated.

RESULTS

Patients were well matched for several preoperative factors. Overall complication rates were significantly higher for the open group. No significant difference was seen in 3-year overall survival between the open and laparoscopic groups (69.2 vs. 73.4 %; p = 0.951). A trend toward better 3-year disease-free survival after laparoscopy was observed (29.7 vs. 50.3 %; p = 0.219), even though the difference did not reach statistical significance. The same trend was seen in subgroup analyses of right and left hepatectomy.

CONCLUSIONS

This study shows the feasibility of LMH for HCC compared to open hepatectomy in regard to both short- and long-term outcomes. LMH offers many advantages commonly attributed to laparoscopy and is well suited for HCC with cirrhosis when performed by experienced surgeons.

Laparoscopic versus open major hepatectomy for hepatocellular carcinoma: a matched pair analysis

BACKGROUND

Laparoscopic major hepatectomy (LMH) for hepatocellular carcinoma (HCC) is currently perceived a complex and challenging laparoscopic procedure and is limited to a few expert teams. This study analyzed the short- and long-term outcomes of LMH for HCC compared with open hepatectomy.

METHODS

From January 2006 to May 2014, 38 patients underwent LMH for HCC (10 left and 28 right hepatectomy). They were matched and compared to 38 patients (10 left and 28 right hepatectomy) who underwent a conventional open approach. Short-term operative and postoperative outcomes as well as long-term outcomes, including disease-free survival and overall survival rates, were evaluated.

RESULTS

Patients were well matched for several preoperative factors. Overall complication rates were significantly higher for the open group. No significant difference was seen in 3-year overall survival between the open and laparoscopic groups (69.2 vs. 73.4 %; p = 0.951). A trend toward better 3-year disease-free survival after laparoscopy was observed (29.7 vs. 50.3 %; p = 0.219), even though the difference did not reach statistical significance. The same trend was seen in subgroup analyses of right and left hepatectomy.

CONCLUSIONS

This study shows the feasibility of LMH for HCC compared to open hepatectomy in regard to both short- and long-term outcomes. LMH offers many advantages commonly attributed to laparoscopy and is well suited for HCC with cirrhosis when performed by experienced surgeons.

Clinical comparison of laparoscopic and open liver resection after propensity matching selection

BACKGROUND

This study aimed to compare the radicality for and clinical advantages of laparoscopic liver resection, which is increasingly used, and the corresponding open procedure by propensity score matching analysis.

METHODS

We analyzed 260 hepatocellular carcinoma patients who underwent initial liver resection at our department between January 2003 and June 2011, including 60 laparoscopic (the Lap group) and 200 open cases (the Open group). Propensity scores were calculated for each patient via the use of various clinicopathologic features as covariates, and patients' survival was compared.

RESULTS

The Lap group had more women and patients of advanced age (n = 60) than the Open group (n = 200). Tumor size (2.3 cm vs 3.5 cm median), multiple tumors (18.3% vs 41.0%), vascular invasion (15.0% vs 36.5%), poor differentiation status (11.2% vs 24.5%), intraoperative bleeding (110 mL vs 420 mL; median), and operative time (277 minutes vs 312 minutes; median) were significantly more favorable in the Lap group than in the Open group because of a selection bias of the patients (Lap vs Open). The postoperative recurrence-free and overall survival rates were greater in the Lap group than in the Open group; however, when 35 patients from each group were analyzed after propensity score matching of clinicopathologic characteristics of the patients, intraoperative bleeding was lesser in the Lap group. The recurrence-free survival rates at 1, 3, and 5 years were 75.0%, 43.8%, and 43.8%, respectively, in the Lap group and 73.6%, 49.3%, and 37.2%, respectively, in the Open group, which indicated no significant differences (P = .954). Similarly, the overall survival rates at 1, 3, and 5 years were 93.9%, 82.1%, and 82.1%, respectively, in the Lap group and 94.3%, 85.2%, and 61.8%, respectively, in the Open group, indicating no significant differences between the 2 groups (P = .672).

CONCLUSION

Our results indicate that laparoscopic liver resection is comparable with the corresponding open procedure in clinical safety and prognostic efficacy.

Risk factors and consequences of conversion in laparoscopic major liver resection

BACKGROUND

Although recent reports have suggested potential benefits of the laparoscopic approach in patients requiring major hepatectomy, it remains unclear whether conversion to open surgery could offset these advantages. This study aimed to determine the risk factors for and postoperative consequences of conversion in patients undergoing laparoscopic major hepatectomy (LMH).

METHODS

Data for all patients undergoing LMH between 2000 and 2013 at two tertiary referral centres were reviewed retrospectively. Risk factors for conversion were determined using multivariable analysis. After propensity score matching, the outcomes of patients who underwent conversion were compared with those of matched patients undergoing laparoscopic hepatectomy who did not have conversion, operated on at the same centres, and also with matched patients operated on at another tertiary centre during the same period by an open laparotomy approach.

RESULTS

Conversion was needed in 30 (13·5 per cent) of the 223 patients undergoing LMH. The most frequent reasons for conversion were bleeding and failure to progress, in 14 (47 per cent) and nine (30 per cent) patients respectively. On multivariable analysis, risk factors for conversion were patient age above 75 years (hazard ratio (HR) 7·72, 95 per cent c.i. 1·67 to 35·70; P = 0·009), diabetes (HR 4·51, 1·16 to 17·57; P = 0·030), body mass index (BMI) above 28 kg/m(2) (HR 6·41, 1·56 to 26·37; P = 0·010), tumour diameter greater than 10 cm (HR 8·91, 1·57 to 50·79; P = 0·014) and biliary reconstruction (HR 13·99, 1·82 to 238·13; P = 0·048). After propensity score matching, the complication rate in patients who had conversion was higher than in patients who did not (75 versus 47·3 per cent respectively; P = 0·038), but was not significantly different from the rate in patients treated by planned laparotomy (79 versus 67·9 per cent respectively; P = 0·438).

CONCLUSION

Conversion during LMH should be anticipated in patients with raised BMI, large lesions and biliary reconstruction. Conversion does not lead to increased morbidity compared with planned laparotomy.

Laparoscopic versus open liver resection for hepatocellular carcinoma at a North-American Centre: a 2-to-1 matched pair analysis

INTRODUCTION

Oncological implications of laparoscopic resection in primary hepatic malignancy are not well defined. Laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) in comparison to an open liver resection (OLR) in peri-operative and long-term oncological outcomes are described from a single North American institution.

METHODS

From 2006 to 2013, all forty-three LLR patients for HCC were evaluated. Each patient was matched to two OLR patients for age at operation, maximal tumour size and tumour number.

RESULTS

When compared with OLR, LLR had a lower severity of complication (0% versus 27%, P = 0.050) and lower 30-day readmission rate (2.3% versus 18.6%, P = 0.010). The length of stay (LOS) was shorter in LLR patients (5 versus 7 days, P < 0.001) and the estimated blood loss was also lower in LLR (300 versus 700 ml, P = 0.004). Admission to intensive care unit (ICU), emergency room (ER) visits and complication rates were similar. Overall, recurrence-free and intra-hepatic recurrence-free survival were comparable between LLR and OLR.

DISCUSSION

LLR confers the widely-accepted benefits of laparoscopic surgery, namely severity of complication, 30-day readmission rate, LOS and blood loss. Further studies are required to examine intra- and extra-hepatic recurrence after LLR. LLR for HCC should be considered for appropriately selected patients in centres with requisite volume and expertise.

Laparoscopic liver resection for the treatment of hepatocellular carcinoma

Accumulation of experiences and technological advances after the first report of laparoscopic liver resection (LLR) are now revealing the characteristics and specific advantages of this approach, especially for hepatocellular carcinoma (HCC) patients with chronic liver diseases (CLD). In laparoscopic approach, there are minimum needs for: (1) laparotomy and dissection of the attachments and adhesion which may cause destructions in the collateral blood and lymphatic flows; and (2) compression of the liver which may cause parenchymal damage for the liver resection (LR). These are especially beneficial for the patients with CLD. LLR results in minimal postoperative ascites and the other complications, which could potentially lead to lowering the risk of fatal liver failure. These characteristics of LLR facilitate surgical treatment application to the patients of HCC with background CLD. Laparoscopic approach also results in improved vision and manipulation in a small operative field under several conditions, including the cases where it is necessary to perform repeat LR between adhesions. These characteristics make LLR safer and more accessible to the repeat treatment, such as multicentric and metachronous lesions in the cirrhotic liver. These advantages of LLR indicate it is a superior method than open LR under certain conditions in patients of HCC with background CLD.

3D visualization reduces operating time when compared to high-definition 2D in laparoscopic liver resection: a case-matched study

OBJECTIVE

To evaluate the effect of three-dimensional (3D) visualization on operative performance during elective laparoscopic liver resection (LLR).

BACKGROUND

Major limitations of conventional laparoscopy are lack of depth perception and tactile feedback. Introduction of robotic technology, which employs 3D imaging, has removed only one of these technical obstacles. Despite the significant advantages claimed, 3D systems have not been widely accepted.

METHODS

In this single institutional study, 20 patients undergoing LLR by high-definition 3D laparoscope between April 2014 and August 2014 were matched to a retrospective control group of patients who underwent LLR by two-dimensional (2D) laparoscope.

RESULTS

The number of patients who underwent major liver resection was 5 (25%) in the 3D group and 10 (25%) in the 2D group. There was no significant difference in contralateral wedge resection or combined resections between the 3D and 2D groups. There was no difference in the proportion of patients undergoing previous abdominal surgery (70 vs. 77%, p = 0.523) or previous hepatectomy (20 vs. 27.5%, p = 0.75). The operative time was significantly shorter in the 3D group when compared to 2D (225 ± 109 vs. 284 ± 71 min, p = 0.03). There was no significant difference in blood loss in the 3D group when compared to 2D group (204 ± 226 in 3D vs. 252 ± 349 ml in 2D group, p = 0.291). The major complication rates were similar, 5% (1/20) and 7.5% (3/40), respectively, (p ≥ 0.99).

CONCLUSION

3D visualization may reduce the operating time compared to high-definition 2D. Further large studies, preferably prospective randomized control trials are required to confirm this.

Can we expand the indications for laparoscopic liver resection? A systematic review and meta-analysis of laparoscopic liver resection for patients with hepatocellular carcinoma and chronic liver disease

Liver resection (LR) for patients with hepatocellular carcinoma (HCC) and chronic liver disease (CLD) poses a high risk of serious postoperative complications and multicentric metachronous lesions requiring repeated treatment. The efficacy of laparoscopic LR (LLR) for such patients has yet to be established. The objective of this study is to test the outcomes of LLR for HCC with the aim of considering potential expansion of the indications for LLR. We performed a systematic review of the pertinent English-language literature. Our search yielded four meta-analyses and 23 comparative studies of LLR for HCC. On the basis of the findings from these studies and our newly conducted meta-analysis, the possibility for expanding the indications for LLR to HCC was examined. The studies show that LLR (vs open) for HCC generally yields better short-term outcomes without compromising long-term outcomes, and that incidences of postoperative ascites and liver failure are decreased with LLR. Several studies show the benefits of LLR for patients with severe CLD and for repeat surgery. Reductions of postoperative ascites and liver failure are among the advantages of LLR. These characteristics of LLR may allow us to expand the indications of LLR to HCC with CLD.

Modified laparoscopic hepatectomy for hepatic hemangioma

BACKGROUND

Laparoscopic hepatectomy (LH) using many different surgical techniques has become increasingly popular for the management of hepatic tumors. The performance of surgical procedures involving the least possible impairment is expected increasingly more often by both surgeons and patients. We herein describe a clinical cohort of ten patients with hepatic cavernous hemangioma (HCH) who underwent modified LH (MLH) with a new technique. We herein present the advantages of the low level of impairment during performance of this modified procedure and compare the outcomes of MLH with those of traditional LH (TLH) for HCH.

METHODS

We retrospectively evaluated the treatment outcomes in 24 patients with HCH who underwent MLH (n = 10) or TLH (n = 14) from February 2008 to January 2013. Their demographic, intraoperative, and postoperative variables were compared.

RESULTS

MLH was successful in all patients. An electromechanical morcellator allowed for easy extraction of the entire HCH without the use of a cumbersome retrieval bag, enlarged incision, or hand-assisted incision. There was no conversion to an open operation or significant perioperative complications. The operation time (P = 0.037), time to removal of the HCH (P < 0.0001), visual analog scale pain score on the first postoperative day (P = 0.012), time to off-bed activity (P = 0.036), and postoperative hospital stay (P = 0.048) were significantly lower in the MLH group than in the TLH group.

CONCLUSIONS

MLH involving the use of an electromechanical morcellator provides expedient recovery and minimal postoperative pain and scarring. It is a feasible, effective, and safe surgical procedure and embodies all of the benefits of minimally invasive surgery for patients with HCH.

Laparoscopic liver resection for living donation: Where do we stand?

In Western countries, living donor liver transplantation (LDLT) may represent a valuable alternative to deceased donor liver transplantation. Yet, after an initial peak of enthusiasm, reports of high rates of complications and of fatalities have led to a certain degree of reluctance towards this procedure especially in Western countries. As for living donor kidney transplantation, the laparoscopic approach could improve patient’s tolerance in order to rehabilitate this strategy and reverse the current trend. In this setting however, initial concerns regarding patient’s safety and graft integrity, need for acquiring surgical expertise in both laparoscopic liver surgery and living donor transplantation and lack of evidence supporting the benefits of laparoscopy have delayed the development of this approach. Similarly to what is performed in classical resectional liver surgery, initial experiences of laparoscopy have therefore begun with left lateral sectionectomy, which is performed for adult to child living donation. In this setting, the laparoscopic technique is now well standardized, is associated with decreased donor blood loss and hospital stays and provides graft of similar quality compared to the open approach. On the other hand laparoscopic major right or left hepatectomies for adult-adult LDLT currently lack standardization and various techniques such as the full laparoscopic approach, the hand assisted approach and the hybrid approach have been reported. Hence, even-though several reports highlight the feasibility of these procedures, the true benefits of laparoscopy over laparotomy remain to be fully assessed. This could be achieved through standardization of the procedures and creation of international registries especially in Eastern countries where LDLT keeps on flourishing.

Laparoscopic liver resection for malignancy: A review of the literature

AIM: To review the published literature about laparoscopic liver resection for malignancy.

METHODS: A PubMed search was performed for original published studies until June 2013 and original series containing at least 30 patients were reviewed.

RESULTS: All forms of hepatic resections have been described ranging from simple wedge resections to extended right or left hepatectomies. The usual approach is pure laparoscopic, but hand-assisted, as well as robotic approaches have been described. Most studies showed comparable results to open resection in terms of operative blood loss, postoperative morbidity and mortality. Many of them showed decreased postoperative pain, shorter hospital stays, and even lower costs. Oncological results including resection margin status and long-term survival were not inferior to open resection.

CONCLUSION: In the hands of experienced surgeons, laparoscopic liver resection for malignant lesions is safe and offers some short-term advantages over open resection. Oncologically, similar survival rates have been observed in patients treated with the laparoscopic approach when compared to their open resection counterparts.

[Laparoscopic liver surgery]

Liver resection remains the method of choice for curative treatment for liver tumors. Development in diagnostic and surgical techniques has improved operative results as well as long-term outcomes. In the last decade minimally invasive laparoscopic (LAP) surgery has been increasingly adopted by liver units. The trend in LAP liver resection has been moving from limited resections towards major hepatectomy. This process, however, is relatively slow, which can be due to technical difficulties of the procedure and fear of haemorrhage. Despite having a hard time at the start, major resections become more common. Up to now approximately 6000 LAP liver resections were performed worldwide, number of major hepatectomies is estimated between 700-800. LAP liver resections are feasible with significant benefits for patients consisting of less blood loss, less narcotic requirements, and shorter hospital stay with comparable postoperative morbidity and mortality to open liver resections. It is an accepted management of both benign and malignant liver lesions. There is no difference between LAP and open surgery in late survival after resection for colorectal liver metastases. Overall survival of LAP resected hepatocellular carcinoma cases seems to be superior compared with open surgery.

Laparoscopic vs open approach to resection of hepatocellular carcinoma in patients with known cirrhosis: Systematic review and meta-analysis

AIM: To review the currently available literature comparing laparoscopic to open resection of hepatocellular carcinoma (HCC) in patients with known liver cirrhosis.

METHODS: A literature search of MEDLINE, EMBASE, and Cochrane databases was conducted. The search terms used included (laparoscopic OR laparoscopy) AND (hepatic or liver) AND (surgery or resection) AND “hepatocellular carcinoma” AND (cirrhosis or cirrhotic). Furthermore, to widen the search, we also used the “related articles” section. Studies reporting a comparison of outcomes and methods of open vs laparoscopic hepatic resection for HCC in patients with liver cirrhosis were included. Meta-analysis of results was performed using a random effects model to compute relative risk (RR) and for dichotomous variables and standard mean differences (SMD) for continuous variables.

RESULTS: A total of 420 patients from 4 cohort studies were included in final analysis. Patients undergoing laparoscopic procedures had statistically less blood loss compared to the open cohort, SMD of -1.01 (95%CI: -1.23-0.79), P < 0.001, with a reduced risk of transfusion, RR = 0.19 (95%CI: 0.09-0.38), P < 0.001. A wider clearance at tumour resection margins was achieved following a laparoscopic approach, SMD of 0.34 (95%CI: 0.08-0.60), P = 0.011. No significant difference was noted between laparoscopic and open resection operative times, SMD of -0.15 (95%CI: 0.35-0.05), P = 0.142. The overall RR of suffering from postoperative morbidity is 0.25 in favour of the open surgery cohort (95%CI: 0.17-0.37), P < 0.001. Patients under-going laparoscopic surgery had significantly shorter length of stays in hospital compared to the open cohort, SMD of -0.53 (95%CI: -0.73 to -0.32), P < 0.001.

CONCLUSION: This review suggests that laparoscopic resection of hepatocellular carcinoma in patients with cirrhosis is safe and may provide improved patient outcomes when compared to the open technique.

Transarterial chemoembolization using drug eluting beads and subsequent percutaneous MR-guided radiofrequency ablation in the therapy of intermediate sized hepatocellular carcinoma

OBJECTIVE

To evaluate safety, efficacy, survival and recurrence-free survival of transarterial chemoembolization (TACE) with drug eluting (DC) beads combined with MR-guided radiofrequency (RF) ablation for the treatment of hepatocellular carcinomas (HCC) larger than 3 cm.

MATERIALS AND METHODS

This retrospective study was approved by the institutional review board. 20 patients (69.6 years ± SD 8.8) with HCC underwent DC Bead TACE and subsequent MR-guided RF ablation. Treatment interval varied between 5 and 15 days. Mean HCC diameter was 39 mm ± SD 7 mm (range 31-50mm). Rates of recurrence-free survival and overall survival were estimated using the Kaplan-Meier method.

RESULTS

Technical success rate, primary and secondary technical effectiveness rate were 100%, 90% and 95%, respectively. Local tumour progression developed in one patient. Cumulative survival rates at 1, 3 and 5 years were 90% (Confidence Interval [CI]: 67%-97%), 50% (CI: 29%-70%), 27% (CI: 11%-51%) respectively. Median survival time was 37.4 months. During follow up (mean: 39.1 months ± SD 22.4; range 5-84 months), tumour progression in untreated liver developed in 14 cases. Cumulative recurrence-free survival rates at 1, 3 and 5 years were 48% (CI: 27-69%), 16% (5-39%), 16% (5-39%) respectively. Median recurrence-free survival time was 10.7 months. One major complication occurred due to misdiagnosed local recurrence.

CONCLUSION

In conclusion, we demonstrated that MR-guided RF ablation with subsequent DC Bead TACE is safe and effective in local tumour control in patients with intermediate sized HCC.

Laparoscopic versus open liver resection for elderly patients with malignant liver tumors: a single-center experience

BACKGROUND

Laparoscopic liver resection is associated with less perioperative blood loss, shorter hospital stay, and fewer postoperative complications in younger patients. However, it remains unclear if these short-term benefits could also be applicable to elderly patients with medical comorbidities.

AIM

To evaluate the perioperative outcomes of laparoscopic liver resection in patients with advanced age.

MATERIALS AND METHODS

Patients aged ≥ 70 years old who received liver resections for malignant liver tumors between January 2002 and December 2012 were included. The perioperative outcomes of 17 patients with laparoscopic approach were matched and compared with 34 patients with conventional open approach in a 1:2 ratio.

RESULTS

There was no significant difference with regard to age, gender, incidence of comorbid illness, hepatitis B positivity, and Child grading of liver function. The median tumor size was 3 cm for both groups. The types of liver resection were similar between the two groups with no significant difference in the duration of operation (laparoscopic: 195 min vs open: 210 min, P = 0.436). The perioperative blood loss was 150 mL in the laparoscopic group and 330 mL in the open group (P = 0.046) with no significant difference in the number of patients with blood transfusion. The duration of hospital stay was 6 days (3-15 days) for the laparoscopic group and 8 days (5-105 days) for the open group (P = 0.005).

CONCLUSION

Laparoscopic liver resection is safe and feasible for elderly patients. The short-term benefits of laparoscopic approach continued to be evident for geriatric oncological liver surgery.

Laparoscopic resection for hepatocellular carcinoma: comparison between Middle Eastern and Western experience

BACKGROUND

Laparoscopic liver resection (LLR) is growing in popularity, but the short- and long-term outcome of patients undergoing LLR for hepatocellular carcinoma (HCC) has not yet been established.

METHODS

A literature search was performed using PubMed, Scopus, and Web of Science (WoS) from cited English and Chinese publications. Clinical and survival parameters were extracted. The search was last conducted in October 2013. After application of selective criteria, 24 remaining original studies with more than 15 patients were analyzed.

RESULTS

In the Western experience, mean operative time was between 150 to 300 minutes, and mean blood loss ranged from 55 to 452 mL. Transfusion was required in all series, ranging from 2.8% to 50%. The conversion rate ranged from 5% to 19.4%. Three cases of death were reported. General morbidity rate ranged from 1.5% to 25%. Specific complications were divided into hemorrhage (2.4% to 25%), ascites (3.7% to 15.3%), and biliary collection (0.6% to 5%). Liver insufficiency was reported in two cases. Mean hospital stay ranged from 5.4 to 15 days. In all case-matched studies, LLR was statistically associated with a shorter hospital stay. The 5-year overall survival rate ranged from 55% to 70%. No trocar-site recurrence was observed. The recurrence rate ranged from 21.4% to 50%. Comparative studies did not demonstrate any significant difference in terms of recurrence between LLR and open liver resection (OLR). In the Middle Eastern experience, mean operative time ranged from 147 to 325 minutes, and mean blood loss ranged from 88 to 808 mL. Transfusion was required, ranging from 1.8% to 19.2%. The conversion rate ranged from 1.8% to 18.6%, and four series reported no conversion. There was no mortality. The main specific complication was ascites (1.7% to 26.6%). A biliary collection was reported in only two series (10.7% and 13.3%), and only one case of postoperative liver insufficiency was reported. Mean hospital stay ranged from 4 to 11.5 days. Statistically, three comparative studies reported a shorter postoperative hospital stay following LLR versus OLR. The 5-year overall survival rate ranged from 50% to 76.6%. Comparative studies did not demonstrate any significant difference in terms of overall survival and recurrence rate between LLR and OLR. No trocar-site recurrence was reported. The recurrence rate ranged from 26.9% to 45.5%, and two series reported no recurrence.

CONCLUSIONS

Laparoscopic surgery should be considered an acceptable alternative for the treatment of HCC.

Laparoscopic liver resections for hepatocellular carcinoma: Current role and limitations

Liver resection for hepatocellular carcinoma (HCC) is currently known to be a safer procedure than it was before because of technical advances and improvement in postoperative patient management and remains the first-line treatment for HCC in compensated cirrhosis. The aim of this review is to assess current indications, advantages and limits of laparoscopic surgery for HCC resections. We also discussed the possible evolution of this surgical approach in parallel with new technologies.

Laparoscopic division of a portosystemic shunt for recurrent life-threatening rectal variceal bleeding: report of a case

In patients with severe portal hypertension related to liver cirrhosis, recanalization of umbilical veins may lead to both development and rupture of massive anorectal varices. In this setting, while transjugular intrahepatic portosystemic shunt (TIPS) is considered as the treatment of choice, the management of these patients remains unclear in case of contraindications to TIPS. Laparoscopic division of massive portosystemic shunts has been reported to yield beneficial effects in patients with isolated hepatic encephalopathy but has never been attempted in a context of life-threatening lower gastrointestinal bleeding. In the present case report, we both describe the operative technique of laparoscopic division of recanalized umbilical veins to treat recurrent massive haemorrhage following rupture of giant rectal varices in a 68-year-old Child C cirrhotic patient contraindicated to TIPS and report the postoperative course of the patient.

Laparoscopic versus open liver resection: a meta-analysis of long-term outcome

BACKGROUND

Laparoscopic liver resection is growing in popularity, but the long-term outcome of patients undergoing laparoscopic liver resection for malignancy has not been established. This paper is a meta-analysis and compares the long-term survival of patients undergoing laparoscopic (LHep) versus open (OHep) liver resection for the treatment of malignant liver tumours.

METHODS

A PubMed database search identified comparative human studies analysing LHep versus OHep for malignant tumours. Clinical and survival parameters were extracted. The search was last conducted on 18 March 2012.

RESULTS

In total, 1002 patients in 15 studies were included (446 LHep and 556 OHep). A meta-analysis of overall survival showed no difference [1-year: odds ratio (OR) 0.71, 95% confidence interval (CI) 0.42 to 1.20, P = 0.202; 3-years: OR 0.76, 95% CI 0.56 to 1.03, P = 0.076; 5-years: OR 0.8, 95% CI 0.59 to 1.10, P = 0.173]. Subset analyses of hepatocellular carcinoma (HCC) and colorectal metastases (CRM) were performed. There was no difference in the 1-, 3-, and 5-year survival for HCC or in the 1-year survival for CRM, however, a survival advantage was found for CRM at 3 years (LHep 80% versus OHep 67.4%, P = 0.036).

CONCLUSIONS

Laparoscopic surgery should be considered an acceptable alternative for the treatment of malignant liver tumours.

Laparoscopic liver resection: a review

Laparoscopic liver surgery was slower to develop than other fields of laparoscopic surgery because of a steep learning curve, and fear of uncontrolled bleeding or gas embolism. However, laparoscopic liver resection (LLR) is associated with significant advantages: faster recovery, less post-operative pain, less morbidity, easier subsequent surgery and better cosmetic results. Since the inception of this technique, more than 3000 procedures have been reported. The aim of this update was to review the literature in order to define the indications (malignant tumors, benign tumors, major resections), the advantages and limits of this approach as well as the expected value of new technology, such as intra-operative guidance or robotics, in the development of this branch of surgery.

Long-term outcome of laparoscopic versus open liver resection for hepatocellular carcinoma: a case-controlled study with propensity score matching

BACKGROUND

Laparoscopic liver resection (LR) for hepatocellular carcinoma (HCC) is usually applied to superficial and left-side small lesions. Therefore, well designed comparative studies about the results of LR versus open liver resection (OR) for HCC are difficult and still uncommon. The aim of this study was to compare the perioperative and long-term oncologic outcomes of LR versus OR for HCC between well-matched patient groups.

METHODS

Between January 2000 and March 2012, 205 patients (43 with intent-to-treat with LR, 162 OR) underwent primary liver resection of less than three segments for HCC in our center. To select a comparison group, propensity score matching (PSM) was used at 1:1 ratio with covariates of baseline characteristics, including tumor characteristics. Outcomes were compared between the matched groups.

RESULTS

The two groups were well balanced by PSM and 29 patients were matched respectively. In LR, there was more non-anatomical resection (65.5 vs. 34.5 %; p = 0.012), less postoperative ascites (0.0 vs. 17.2 %; p = 0.025), and shorter hospital stay (7.69 ± 2.94 vs. 13.38 ± 7.37 days; p < 0.001). With the exception of these, there were no significant differences in perioperative and long-term outcomes. The 1-, 3- and 5-year survivals were 100, 100 and 92.2 % in LR, and 96.5, 92.2 and 87.7 % in OR (p = 0.267), respectively. The 1-, 3- and 5-year disease-free survivals were 81.7, 61.7 and 54.0 % in LR, and 78.6, 60.9 and 40.1 % in OR, respectively (p = 0.929).

CONCLUSIONS

The outcome of LR for HCC was technically feasible and safe in selected patients, and LR showed similar perioperative and long-term oncologic outcomes when compared with OR matched with PSM.

Pure laparoscopic hepatectomy for hepatocellular carcinoma with chronic liver disease

Pure laparoscopic hepatectomy is a less invasive procedure than conventional open hepatectomy for the resection of hepatic lesions. Increases in experiences with the technique, in combination with advances in technology, have promoted the popularity of pure laparoscopic hepatectomy. However, indications for usage and potential contraindications of the procedure remain unresolved. The characteristics and specific advantages of the procedure, especially for hepatocellular carcinoma (HCC) patients with chronic liver diseases, are reviewed and discussed in this paper. For cirrhotic patients with liver tumors, pure laparoscopic hepatectomy minimizes destruction of the collateral blood and lymphatic flow from laparotomy and mobilization, and mesenchymal injury from compression. Therefore, pure laparoscopic hepatectomy has the specific advantage of minimal postoperative ascites production that leads to lowering the risk of disturbance in water or electrolyte balance and hypoproteinemia. It minimizes complications that routinely trigger postoperative serious liver failure. Under adequate patient positioning and port arrangement, the partial resection of the liver in the area of subphrenic space, peri-inferior vena cava area or next to the attachment of retro-peritoneum is facilitated in pure laparoscopic surgery by providing good vision and manipulation in the small operative field. Furthermore, the features of reduced post-operative adhesion, good vision, and manipulation within the small area between the adhesions make this procedure safer in the context of repeat hepatectomy procedures. These improved features are especially advantageous for patients with liver cirrhosis and multicentric and/or metachronous HCCs.

Laparoscopic hepatic resection for metastatic liver tumor of colorectal cancer: comparative analysis of short- and long-term results

BACKGROUND

With the progress of surgical techniques and devices, laparoscopic hepatectomy (Lap-Hx) became a realizable option for patients with liver tumors. However, the feasibility of Lap-Hx for metastatic liver tumor of colorectal cancer also should be guaranteed oncologically. This study evaluated the short- and long-term outcomes of Lap-Hx compared with open hepatectomy (Open-Hx) for patients with colorectal liver metastasis (CLM) by matched-pair analysis.

METHODS

This study enrolled 21 patients who underwent Lap-Hx and compared them with 21 matched patients who underwent Open-Hx. The following parameters were matched between the two cohorts: tumor size, tumor location, and operative procedures. Both short- and long-term outcomes of Lap-Hx were compared with those of Open-Hx.

RESULTS

No difference was observed between the two groups in terms of age, gender, tumor size, or operative procedures. With regard to short-term outcomes, the operative time for Lap-Hx (377 ± 29 min) was similar to that for Open-Hx (369 ± 31 min), whereas the blood loss for the patients who underwent a Lap-Hx (198 ± 39 ml) was significantly less than for those who underwent an Open-Hx (326 ± 50 ml). The incidence of postoperative complications among the patients who underwent Lap-Hx tended to be lower than for the patients who underwent Open-Hx, and intraabdominal abscess was observed only in the Open-Hx group. The hospital stay for Lap-Hx (average, 18.3 days) tended to be shorter than for Open-Hx (27 days). With respect to long-term outcomes, the two groups did not differ significantly in terms of 5-year overall and disease-free survival rates.

CONCLUSIONS

Lap-Hx is a safe and feasible option for selected patients with CLM. The short- and long-term outcomes of Lap-Hx also are considered to be acceptable.

Surgical therapy for hepatocellular carcinoma: formulating a rational approach

Hepatocellular carcinoma is one of the most common malignancies worldwide, and its incidence continues to rise in the United States. Partial hepatectomy and liver transplantation remains the mainstay of treatment for localized disease and provides significant improvement in long-term survival, as well as the potential for cure. The indications and criteria for resection and transplantation are well established, but continue to undergo significant modification over time. Surgical resection is the primary therapeutic modality in patients with well-compensated liver disease, and transplantation is highly effective in early-stage tumors in patients with severe underlying liver disease. The relative role for each of these modalities must be tailored to individual patients based on a rational approach designed to balance quality of life, organ allocation, and patient survival.