Outcome for patients treated with laparoscopic versus open resection of hepatocellular carcinoma: case-matched analysis

Colorectal cancer liver metastases: laparoscopic and open radiofrequency-assisted surgery

INTRODUCTION

The liver is the most common site of colorectal metastases (colorectal liver metastases - CLM). Surgical treatment in combination with oncological therapy is the only potentially curative method. Unfortunately, only 10-25% of patients are suitable for surgery. Traditionally, open liver resection (OLR) is usually performed. However, laparoscopic liver resection (LLR) has become popular worldwide in the last two decades.

AIM

To evaluate the effectiveness and benefits of radiofrequency minor LLR of CLM in comparison with OLR.

MATERIAL AND METHODS

The indication for surgery was CLM and the possibility to perform minor laparoscopic or OLR not exceeding two hepatic segments according to Couinaud's classification.

RESULTS

Sixty-six minor liver resections for CLM were performed. Twenty-five (37.9%) patients underwent a laparoscopic approach and 41 (62.1%) patients underwent OLR. The mean operative time was 166.4 min for LLR and 166.8 min for OLR. Average blood loss was 132.3 ±218.0 ml during LLR and 149.5 ±277.5 ml during OLR. Length of hospital stay was 8.4 ±2.0 days for LLR and 10.5 ±5.8 days for OLR. All resections were R0. There was no case of mortality. Postoperative complications were recognized in 9 (13.6%) patients: 8 in the group of OLR patients and 1 in the LLR group. The median survival time for LLR was 70.5 months and for OLR 61.9 months. The 5-year overall survival rate was higher for LLR vs. OLR - 82.1% vs. 69.8%. The average length of disease-free interval after LLR was greater (52.2 months) in comparison with OLR (49.4%). The 5-year disease-free interval was 63.2% for LLR and 58% for OLR.

CONCLUSIONS

Outcomes and oncological radicality of minor laparoscopic liver resections of CLM are comparable to outcomes of OLR.

Laparoscopic versus open liver resection for hepatocellular carcinoma in posterosuperior segments

BACKGROUND

Traditional open liver resection remains the classic procedure for hepatocellular carcinoma (HCC) located in the posterosuperior segments of the liver (segments I, IVa, VII, and VIII). This study compared the perioperative and oncologic results for laparoscopic versus open liver resection of HCC located in the posterosuperior segments, especially in patients with cirrhosis.

METHODS

This study included 41 patients who underwent laparoscopic liver resection (LLR) and 86 who underwent open liver resection (OLR) for HCC in the posterosuperior segments between January 1, 2010, and December 31, 2012. There perioperative course and oncologic outcomes were retrospectively evaluated.

RESULTS

There were no significant differences between the LLR and OLR groups in length of operation (242.41 ± 73.69 vs. 235.38 ± 65.80 min), transfusion rate (7.3 vs. 14.0 %), R0 resection rate (100 vs. 97.7 %), or tumor size (4.22 ± 2.05 vs. 4.30 ± 1.49 cm). In contrast, postoperative hospital stay (9.44 ± 2.72 vs. 14.53 ± 6.03 days) was significantly shorter, and postoperative complication rates (17.1 vs. 37.2 %) and intraoperative blood loss (272.20 ± 170.86 vs. 450.12 ± 344.70 mL) significantly lower in the LLR than in the OLR group. In addition, there was no significant difference between the two groups (LLR vs. OLR) regarding 1-year overall survival rate (95.1 vs. 89.5 %), 3-year overall survival rate (78 vs. 76.7 %,), 1-year disease-free survival rate (87.8 vs. 82.6 %,), and 3-year disease-free survival rate (70.7 vs. 68.6 %).

CONCLUSIONS

LLR for selected patients with HCC in the posterosuperior segments may offer the same oncologic outcomes as conventional procedures, while being associated with such advantages as lower blood loss, fewer postoperative complications, and shorter hospital stay.

Learning curve for laparoscopic major hepatectomy

BACKGROUND

Laparoscopic major hepatectomy (LMH) is evolving as an important surgical approach in hepatopancreatobiliary surgery. The present study aimed to evaluate the learning curve for LMH at a single centre.

METHODS

Data for all patients undergoing LMH between January 1998 and September 2013 were recorded in a prospective database and analysed. The learning curve for operating time (OT) was evaluated using the cumulative sum (CUSUM) method.

RESULTS

Of 173 patients undergoing major hepatectomy, left hepatectomy was performed in 28 (16·2 per cent), left trisectionectomy in nine (5·2 per cent), right hepatectomy in 115 (66·5 per cent), right trisectionectomy in 13 (7·5 per cent) and central hepatectomy in eight (4·6 per cent). Median duration of surgery was 270 (range 100-540) min and median blood loss was 300 (10-4500) ml. There were 20 conversions to an open procedure (11·6 per cent). Vascular clamping was independently associated with conversion on multivariable analysis (hazard ratio 5·95, 95 per cent c.i. 1·24 to 28·56; P = 0·026). The CUSUMOT learning curve was modelled as a parabola (CUSUMOT  = 0·2149 × patient number(2)  - 30·586 × patient number - 1118·3; R(2)  = 0·7356). The learning curve comprised three phases: phase 1 (45 initial patients), phase 2 (30 intermediate patients) and phase 3 (the subsequent 98 patients). Although right hepatectomy was most common in phase 1, a significant decrease was observed from phase 1 to 3 (P = 0·007) in favour of more complex procedures.

CONCLUSION

The learning curve for LMH consisted of three characteristic phases identified by CUSUM analysis. The data suggest that the learning phase of LMH included 45 to 75 patients.

Pure laparoscopic liver resection for large malignant tumors: does size matter?

BACKGROUND

Laparoscopic liver resection (LLR) for large malignant tumors can be technically challenging. Data on this topic are scarce, and many question its feasibility, safety, and oncologic efficiency. This study aimed to assess outcomes of LLR for large (≥ 5 cm) and giant (≥ 10 cm) malignant liver tumors.

METHODS

A prospectively collected database of 422 LLRs was reviewed from August 2003 to August 2013. The data for 52 patients undergoing LLR for large malignant tumors were analyzed. A subgroup analysis of giant tumors also is reported.

RESULTS

During the period studied, 52 LLRs were performed (males, 53.8 %; mean age, 64.6 years) for large malignant tumors. Colorectal liver metastasis was the most common indication (42.3 %). The 52 LLRs included 32 major (61.5 %) and 20 minor (38.5 %) LLRs for tumors with a mean diameter of 83 mm. The median operative time was 240 min [interquartile range (IQR), 150-330 min], and the blood loss was 500 ml (IQR, 200-1,373 ml). Eight conversions (15.4 %) were performed. Six patients experienced complications (11.5 %). Among the 44 patients with successful LLRs, two patients (4.5 %) had an R1 resection. The median hospital stay was 5 days (range, 1-21 days), and no mortality occurred during a 90-day period. A subgroup analysis of patients with giant tumors showed greater blood loss (p = 0.002) and a longer operative time (p = 0.052) but no difference in terms of conversions (p = 0.64) or complications (p = 0.32).

CONCLUSION

The findings showed that LLR is feasible and safe for large malignant tumors and can be performed with acceptable morbidity and oncologic efficiency. When used for giant malignant tumors, LLR is associated with greater blood loss and a longer operative time but no increase in complications.

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.

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.

From minimal to maximal surgery in the treatment of hepatocarcinoma: A review

Hepatocellular carcinoma represents one of the most challenging frontiers in liver surgery. Surgeons have to face a broad spectrum of aspects, from the underlying liver disease to the new surgical techniques. Safe liver resection can be performed in patients with portal hypertension and well-compensated liver function with a 5-year survival rate of 50%, offering good long-terms results in selected patients. With the advances in laparoscopic surgery, major liver resections can be performed with minimal harm, avoiding the wound and leak complications related to the laparotomies. Studies have shown that oncological margins are the same as in open surgery. In patients submitted to liver resection (either laparoscopic or open) who experience recurrence, re-resection or salvage liver transplantation has been showing to be an alternative approach in well selected cases. The decision making approach to the cirrhotic patient is becoming more complex and should involve hepatologists, liver surgeons, radiologists and oncologists. Better understanding of the different risk factors for recurrence and survival should be aimed in these multidisciplinary discussions. We here in discuss the hot topics related to surgical risk factors regarding the surgical treatment of hepatocellular carcinoma: anatomical resection, margin status, macrovascular tumor invasion, the place of laparoscopy, salvage liver transplantation and liver transplantation.

Risk factors for complications after laparoscopic major hepatectomy

BACKGROUND

Although laparoscopic major hepatectomy (MH) is becoming increasingly common in several specialized centres, data regarding outcomes are limited. The aim of this study was to identify the risk factors for postoperative complications of purely laparoscopic MH at a single centre.

METHODS

All patients who underwent purely laparoscopic MH between January 1998 and March 2014 at the authors' institution were enrolled. Demographic, clinicopathological and perioperative factors were collected prospectively, and data were analysed retrospectively. The dependent variables studied were the occurrence of overall and major complications (Dindo-Clavien grade III or above).

RESULTS

A total of 183 patients were enrolled. The types of MH included left-sided hepatectomy in 40 patients (21·9 per cent), right-sided hepatectomy in 135 (73·8 per cent) and central hepatectomy in eight (4·4 per cent). Median duration of surgery was 255 (range 100-540) min, and median blood loss was 280 (10-4500) ml. Complications occurred in 100 patients (54·6 per cent), and the 90-day all-cause mortality rate was 2·7 per cent. Liver-specific and general complications occurred in 62 (33·9 per cent) and 38 (20·8 per cent) patients respectively. Multivariable analysis identified one independent risk factor for global postoperative complications: intraoperative simultaneous radiofrequency ablation (RFA) (odds ratio (OR) 6·93, 95 per cent c.i. 1·49 to 32·14; P = 0·013). There were two independent risk factors for major complications: intraoperative blood transfusion (OR 2·50, 1·01 to 6·23; P = 0·049) and bilobar resection (OR 2·47, 1·00 to 6·06; P = 0·049).

CONCLUSION

Purely laparoscopic MH is feasible and safe. Simultaneous RFA and bilobar resection should probably be avoided.

Intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma (ICC) is a rare tumor, with an increasing incidence worldwide and an overall poor prognosis. Symptoms are usually nonspecific, contributing to an advanced tumor stage at diagnosis. The staging system for ICC has recently been updated and is based on number of lesions, vascular invasion, and lymph node involvement. Complete surgical resection to negative margins remains the only potentially curable treatment for ICC. Gemcitabine-based adjuvant therapy can be offered based on limited data from patients with unresectable ICC. Overall 5-year survivals after resection range from 17% to 44%, with median survivals of 19 to 43 months.

Laparoscopic liver resection: Wedge resections to living donor hepatectomy, are we heading in the right direction?

Despite inception over 15 years ago and over 3000 completed procedures, laparoscopic liver resection has remained mainly in the domain of selected centers and enthusiasts. Requirement of extensive open liver resection (OLR) experience, in-depth understanding of anatomy and considerable laparoscopic technical expertise may have delayed wide application. However healthy scepticism of its actual benefits and presence of a potential publication bias; concern about its safety and technical learning curve, are probably equally responsible. Given that a large proportion of our work, at least in transplantation is still OLR, we have attempted to provide an entirely unbiased, mature opinion of its pros and cons in the current invited review. We have divided this review into two sections as we believe they merit separate attention on technical and ethical grounds. The first part deals with laparoscopic liver resection (LLR) in patients who present with benign or malignant liver pathology, wherein we have discussed its overall outcomes; its feasibility based on type of pathology and type of resection and included a small section on application of LLR in special scenarios like cirrhosis. The second part deals with the laparoscopic living donor hepatectomy (LDH) experience to date, including its potential impact on transplantation in general. Donor safety, graft outcomes after LDH and criterion to select ideal donors for LLR are discussed. Within each section we have provided practical points to improve safety in LLR and attempted to reach reasonable recommendations on the utilization of LLR for units that wish to develop such a service.

Laparoscopic versus open liver resection for metastatic colorectal cancer: a metaanalysis of 610 patients

BACKGROUND

Laparoscopic liver resection (LLR) for metastatic colorectal cancer (mCRC) remains controversial. The objective of this manuscript was to perform a metaanalysis comparing outcomes of LLR with open liver resection (OLR) in patients with hepatic mCRC, and to identify which patients were suitable candidates for LLR.

STUDY DESIGN

A PubMed search identified 2,122 articles. When filtered for case-matched articles comparing LLR with OLR for mCRC, 8 articles were identified consisting of 610 patients (242 LLR, 368 OLR). A random effects metaanalysis was performed.

RESULTS

The 2 groups were well-matched for age, sex, American Society of Anesthesiologists score, tumor size, number of metastases, extent of major hepatectomy, and use of neoadjuvant/adjuvant chemotherapy. The mean number of metastases in the LLR and OLR groups were 1.4 and 1.5, respectively (P = .14). Estimated blood loss was less in LLR group (262 vs 385 mL; P = .049). Transfusion rate was significantly less in LLR group (9.9 vs 19.8%; P = .004). There was no difference in operative time (248.7 vs 262.8 min; P = .85). Length of stay (LOS) was less in the LLR group (6.5 vs 8.8 days; P = .007). The overall complication rate was less in LLR group (20.3% vs 33.2%; P = .03). Importantly, there was no difference in the 1-, 3-, and 5-year disease-free survival (DFS) or overall survival (OS) rates.

CONCLUSION

In carefully selected patients with limited mCRC (1 or 2 tumors), LLR provides marked perioperative benefits without compromising oncologic outcomes or long-term survival. Specifically, LLR offers decreased blood loss, LOS, and overall complication rates with comparable 5-year OS and DFS.

Short- and long-term outcomes of laparoscopic versus open hepatectomy for small malignant liver tumors: a single-center experience

BACKGROUND

Laparoscopic hepatectomy (Lap-Hx) has been increasingly performed for patients with liver tumors as surgical techniques and devices have progressed. However, the long-term outcomes of Lap-Hx for malignant liver tumors are not oncologically guaranteed. This study compared the short- and long-term outcomes between Lap-Hx and open hepatectomy (Open-Hx) for malignant liver tumors by matched-pair analysis.

METHODS

The indications for Lap-Hx at our department are a tumor size of <5 cm and fewer than two lesions without macroscopic vascular invasion or the need for biliary reconstruction. In total, 135 patients underwent Lap-Hx for malignant liver tumors through December 2013. We compared the short- and long-term outcomes between Lap-Hx and Open-Hx in patients who met the above-mentioned indications.

RESULTS

With respect to short-term outcomes, the operation time, blood loss, postoperative hospital stay, white blood cell count, and C-reactive protein level after Lap-Hx were significantly better than those after Open-Hx in both the patients who underwent partial resection and those who underwent lateral sectionectomy. In patients who underwent partial resection, the incidence of postoperative complications after Lap-Hx was significantly lower than that after Open-Hx; in particular, wound infection and respiratory complications were significantly lower. Furthermore, when the tumor was located in the posterosuperior segments, the operation time for Lap-Hx was not shorter than that for Open-Hx. With respect to long-term outcomes of hepatocellular carcinoma, neither overall nor disease-free survival differed between the two groups. With respect to long-term outcomes of colorectal liver metastases, the disease-free survival rate was similar between Lap-Hx and Open-Hx; however, the overall survival rate was significantly better for Lap-Hx than for Open-Hx.

CONCLUSIONS

Lap-Hx is a good option for selected patients with malignant liver tumors. The short- and long-term outcomes of Lap-Hx also are considered to be acceptable.

Matching methods to create paired survival data based on an exposure occurring over time: a simulation study with application to breast cancer

Background

Paired survival data are often used in clinical research to assess the prognostic effect of an exposure. Matching generates correlated censored data expecting that the paired subjects just differ from the exposure. Creating pairs when the exposure is an event occurring over time could be tricky. We applied a commonly used method, Method 1, which creates pairs a posteriori and propose an alternative method, Method 2, which creates pairs in “real-time”. We used two semi-parametric models devoted to correlated censored data to estimate the average effect of the exposure HR¯(t): the Holt and Prentice (HP), and the Lee Wei and Amato (LWA) models. Contrary to the HP, the LWA allowed adjustment for the matching covariates (LWA_a) and for an interaction (LWA_i) between exposure and covariates (assimilated to prognostic profiles). The aim of our study was to compare the performances of each model according to the two matching methods.

Methods

Extensive simulations were conducted. We simulated cohort data sets on which we applied the two matching methods, the HP and the LWA. We used our conclusions to assess the prognostic effect of subsequent pregnancy after treatment for breast cancer in a female cohort treated and followed up in eight french hospitals.

Results

In terms of bias and RMSE, Method 2 performed better than Method 1 in designing the pairs, and LWA_a was the best model for all the situations except when there was an interaction between exposure and covariates, for which LWA_i was more appropriate. On our real data set, we found opposite effects of pregnancy according to the six prognostic profiles, but none were statistically significant. We probably lacked statistical power or reached the limits of our approach. The pairs’ censoring options chosen for combination Method 2 - LWA had to be compared with others.

Conclusions

Correlated censored data designing by Method 2 seemed to be the most pertinent method to create pairs, when the criterion, which characterized the pair, was an exposure occurring over time. In such a setting, the LWA was the most appropriate model.

Recent advances in liver resection for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy. The association of HCC with chronic liver disease (CLD) is well known and making treatment complex and challenging. The treatment of HCC must take into consideration, the severity of CLD, the stage of HCC, and the clinical condition of the patient. Liver resection (LR) is one of the most efficient treatments for patients with HCC. Better liver function assessment, increased understanding of segmental liver anatomy using more accurate imaging studies, and surgical technical progress are the important factors that have led to reduced mortality, with an expected 5 year survival of 38–61% depending on the stage of the disease. However, the procedure is applicable to <30% of all HCC patients, and 80% of the patients after LR recurred within 5 years. There are recent advances and prospects in LR for HCC in several aspects. Three-dimensional computed tomography imaging assisted preoperative surgical planning facilitates unconventional types of LR. Emerging evidences of laparoscopic hepatectomy and prospects for the use of newly developing chemotherapies as a combined therapy may lead to expanding indication of LR. LR and liver transplantation could be associated rather than considered separately with the current concepts of “bridging LR” and “salvage transplantation.”

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 resection of hepatocellular carcinoma: when, why, and how? A single-center experience

PURPOSE

The aim of this study was to evaluate short- and intermediate-term results of laparoscopic liver resection in selected patients with hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

Eighty-five patients with HCC were subjected to liver resection between February 2007 and January 2013. From these, 30 (35.2%) were subjected to laparoscopic liver resection and were retrospectively analyzed. Special emphasis was given to the indication criteria and to surgical results.

RESULTS

There were 21 males and 9 females with a mean age of 57.4 years. Patients were subjected to 10 nonanatomic and 20 anatomic resections. Two patients were subjected to hand-assisted procedures (right posterior sectionectomies); all other patients were subjected to totally laparoscopic procedures. Conversion to open surgery was necessary in 4 patients (13.3%). Postoperative complications were observed in 12 patients (40%), and the mortality rate was 3.3%. Mean overall survival was 29.8 months, with 3-year overall and disease-free survival rates of 76% and 58%, respectively.

CONCLUSIONS

Laparoscopic treatment of selected patients with HCC is safe and feasible and can lead to good short- and intermediate-term results.

Comparison of short- and long-term outcomes after extralevator abdominoperineal excision and standard abdominoperineal excision for rectal cancer: a systematic review and meta-analysis

PURPOSE

Whether the introduction of extralevator abdominoperineal excision (ELAPE) improves survival and safety remains controversial. We conducted a systematic review and meta-analysis of all comparative studies to define the efficacy and safety of ELAPE and standard abdominoperineal excision (APE).

MATERIALS AND METHODS

A search for all major databases and relevant journals from inception to July 2013 without restriction on languages or regions was performed. Outcome measures were the oncological parameters of circumferential resection margin (CRM) involvement, intraoperative bowel perforation (IOP), and local recurrence, as well as other parameters of blood loss, operative time, length of hospitalization, and postoperative complication. The test of heterogeneity was performed with the Q statistic.

RESULTS

A total of 949 patients were included in the meta-analysis. Oncological pooled estimates of intraoperative bowel perforation rate (RR 0.34; 95 % CI 0.21-0.54; P < 0.00001), CRM involvement (RR 0.44; 95 % CI 0.34-0.56; P < 0.00001), and local recurrence (RR 0.32; 95 % CI 0.14-0.74; P = 0.008) all showed outcomes that were significantly lower in ELAPE than in APE. A similar incidence of postoperative complication was attributed to both groups, including overall complication (RR 0.93; 95 % CI 0.66-1.32; P = 0.69), perineal wound complication (RR 0.72; 95 % CI 0.33-1.55; P = 0.39), and urinary dysfunction (RR 1.53; 95 % CI 0.88-2.67; P = 0.13).

CONCLUSION

ELAPE has a lower intraoperative bowel perforation rate, positive CRM rate, and local recurrence rate than APE. There is evidence that in selected low rectal cancer patients, ELAPE is a more efficient and equally safe option to replace APE. Due to the inherent limitations of the present study, future randomized controlled trials will be useful to confirm this conclusion.

Laparoscopic liver surgery: An overview of the literature and experiences of a single centre

In the past two decades there has been an enormous increase in laparoscopic liver surgery. There is a trend from limited to laparoscopic major resections and more centres are adopting laparoscopic liver surgery as a standard of care. Although no randomized clinical trials are published, different reports on minor and major hepatectomies and meta-analyses suggest (at least) equal outcomes and cost-effectiveness compared to open procedures.

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.

Evaluation of a laparoscopic liver resection in the setting of cirrhosis

INTRODUCTION

Patients presenting with cirrhosis and hepatic tumours represent a fragile group that have typically been avoided in early series of laparoscopic liver resection. This study was undertaken to evaluate the results of a laparoscopic hepatectomy in the setting of cirrhosis.

METHODS

Subgroup analysis of patients with cirrhosis within a series of 327 patients undergoing a laparoscopic resection was performed. Comparisons were made with patients without cirrhosis where appropriate to highlight differences in patient selection and outcomes. Specific variables assessed included operative details and short-term outcomes including length of stay (LOS), morbidity and mortality. Outcomes specific to hepatocellular carcinoma (HCC) were also assessed.

RESULTS

There were 52 patients with cirrhosis undergoing a laparoscopic hepatic resection. Ninety per cent of patients were Childs class A, with a median model for end-stage liver disease (MELD) score of 8. Hepatitis C was the most common cause of cirrhosis (88.5%), whereas the most common indication for an operation was HCC (71.2%). Resections were generally limited, with the median number of segments resected being 2 (range: 1-4). Complications occurred in 13 (25%) patients, with a 90-day mortality of 5.8%. The median LOS was 3 days.

CONCLUSIONS

A laparoscopic hepatectomy is safe in the setting of cirrhosis, provided the application of appropriate selection criteria and sufficient experience with the procedure.

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.

Laparoscopic liver resection: 5-year experience at a single center

Background

Hepatocellular carcinoma (HCC) is a common cancer, especially in the Association of Southeast Asian Nations (ASEAN) region, where the prevalence of hepatitis virus infection is high. Liver resection is a potentially curative and popular therapy for HCC. Laparoscopic surgery using minimally invasive techniques potentially brings benefits to patients who need liver resection for HCC. This study aimed to evaluate the effectiveness, safety, and benefits of laparoscopic liver resection for HCC with long-term follow-up evaluation.

Methods

This cohort study with 5-year results of total laparoscopic hepatectomy for HCC was conducted in one center. Patients with HCC were selected for laparoscopic liver resection by the same team. The operation also was performed by one team of surgeons. The follow-up protocol was similar to that for open surgery. The patients were scheduled to return for examination every 2 months after the operation. The data for the patients were collected and analyzed using SPSS software.

Results

From January 2008 to December 2012, 173 enrolled patients with HCC underwent laparoscopic liver resection. The male-to-female ratio was 3:1. The mean age of the patients was 56 years (range 16–83 years). The follow-up period for 130 patients was 21.6 ± 16.0 months (range 0–60 months). The mean tumor size was 3.73 cm (range 2–10 cm). The stages of HCC according to the Barcelona Clinic Liver Cancer (BCLC) categorization were as follows: 0 (6 %), A1 (59.5 %), A2 (6.9 %), A4 (2.9 %), and B (27.2 %). Four patients required conversion to other techniques (2.3 %) because of the potential for major bleeding and tumor perforation. The types of resection were resection of one segment (segments 2, 3, 4, 5, 6, 7, and 8; 43.8 %), resection of two segments (posterior sector, anterior sector, segments 5 and 6, and left lateral sector; 47.9 %), resection of three segments (left and central liver; 4.7 %), and four segments (right liver; 3.6 %). The mean operation time was 112 ± 56 min (range 30–345 min), and the median blood loss was 100 ml (range 20–1,200 ml). The mean hospital stay was 6.5 ± 2.0 days (range, 3–19 days). No perioperative mortality occurred. The overall survival rates were 94.2 % at 1 year, 87 % at 2 years, 72.9 % at 3 years, 72.9 % at 4 years, and 72.9 % at 5 years. The mean overall survival time was 49.7 ± 2.1 months (range 45.5–53.9 months). The disease-free survival rates were 79.1 % at 1 year, 60 % at 2 years, 57 % at 3 years, 52 % at 4 years, and 26.3 % at 5 years. The mean disease-free survival time was 38.9 ± 2.6 months (range 33.9–44.0 months).

Conclusion

Laparoscopic liver resection for HCC is feasible, safe, and effective, with good oncologic results. Major and anatomic hepatectomy are possible with improved skill and experience. Laparoscopic liver resection is a promising treatment option with minimally invasive benefits for HCC patients.

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.

Feasibility and safety of laparoscopic liver resection for hepatocellular carcinoma with a tumor size of 5-10 cm

Background

Although laparoscopic liver resection has developed rapidly and gained widespread acceptance for the treatment of benign liver diseases and hepatocellular carcinoma with a small tumor size, 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 safety and feasibility of laparoscopic liver resection for the treatment of hepatocellular carcinoma with a tumor size of 5–10 cm.

Methods

From March 2007 to December 2011, we performed liver resection in 275 patients with hepatocellular carcinoma with a tumor size of 5–10 cm. Laparoscopic liver resection was performed in 97 patients (Lap-Hx group) and open liver resection was performed in 178 patients (Open-Hx group). Operative time, estimated intraoperative blood loss, blood transfusion rate, and length of postoperative hospital stay were compared between the two groups. Early and intermediate-term postoperative outcomes were also compared.

Results

Only one liver resection was performed for every patient with HCC in the present study.No operative deaths occurred in either group. Nine of the laparoscopic procedures were converted to open resection (conversion rate 9.28%). There were no significant differences in mean operative time (245±105 min vs 225±112 min; P = .469), mean estimated intraoperative blood loss (460±426 mL vs 454±365 mL; P = .913), or blood transfusion rate (4.6%, 4/88) vs (2.8%, 5/178)(P = .480) between the Lap-Hx and Open-Hx groups. However, postoperative hospital stay was shorter in the Lap-Hx group than the Open-Hx group (8.2±3.6 days vs 13.5±3.8 days; P = .028). There was a lower rate of postoperative complications in the Lap-Hx group than the Open-Hx group (9% vs 30%; P = .001), but there were no severe complications in either group. The median overall follow-up time was 21 months (range 2–50 months) and the median follow-up of time of survivors was 23 months. The median follow-up time was 25 months in the Lap-Hx group and 20 months in the Open-Hx group. The follow-up rate was 95% (84 patients) in the Lap-Hx group and 95% (169 patients) in the Open-Hx group, which was not a significant difference between the two groups (P = .20). Tumor recurrence occurred in 17 patients (20%) in the Lap-Hx group and 35 patients (21%) in the Open-Hx group, which was not a significant difference between the two groups (P = .876). A total of 33 patients (13%) died during the study period, including 12 patients (14%) in the Lap-Hx group and 21 patients (12%) in the Open-Hx group, which was not a significant difference between the two groups (P = .695). There were also no significant differences in the 1-year rates of overall survival (94% vs 95%; P = .942) or disease-free survival (93% vs 92%; P = .941), or the 3-year rates of overall survival (86% vs 88%; P = .879) or disease-free survival (66% vs 67%; P = .931), between the Lap-Hx and Open-Hx groups.

Conclusions

Laparoscopic liver resection is safe and feasible in patients with hepatocellular carcinoma with a tumor size of 5–10 cm. Laparoscopic liver resection can avoid some of the disadvantages of open resection, and is beneficial in selected patients based on preoperative liver function, tumor size and location.

Laparoscopic major hepatectomy: pure laparoscopic approach versus hand-assisted technique

Laparoscopic liver resections are being performed with increasing frequency, with several groups having reported minimally invasive approaches for major anatomic hepatic resections. Some surgeons favor a pure laparoscopic approach, while others prefer a hand-assisted approach for major laparoscopic liver resections. There are clear advantages and disadvantages to a hand-assisted technique. The purpose of this study is to summarize the literature comparing pure laparoscopic and hand-assisted approaches for minimally invasive hepatic resection, and to describe our approach in 432 laparoscopic liver resections.

Laparoscopic versus open liver resection for benign and malignant hepatic lesions in adults

BACKGROUND

Liver (hepatic) resection refers to removal of the whole liver, or one or more of its vascular segments. Elective liver resection is mainly performed for benign and malignant liver tumours. The operation can be performed as an open procedure or with a laparoscopic approach. With the advancement of laparoscopic skills and equipment, liver resection is selectively being carried out with this approach. A laparoscopic procedure is intended to be less severe, allowing for quicker healing, fewer complications, and a shorter hospital stay as the insult to the body is minimised. However, evidence about the efficacy of this approach when compared to an open procedure is still scattered. Current practice at different hepato-pancreato-biliary centres is based on the clinical judgement of experts in their field, which is highly insufficient in terms of evidence.

OBJECTIVES

To assess the benefits and harms of laparoscopic versus open liver resection for benign or malignant lesions on the liver in adult patients.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until February 2013. We also conducted searches of reference lists of relevant articles and reviews, conference proceedings, and ongoing trial databases.

SELECTION CRITERIA

We searched for randomised clinical trials of participants undergoing liver resection for benign or malignant lesions which reported on benefits and harms. We searched for quasi-randomised or observational studies for reports of harm.

DATA COLLECTION AND ANALYSIS

No data from randomised clinical trials could be collected.

MAIN RESULTS

Two authors performed study selection independently. We were not able to identify any randomised clinical trials that met the inclusion criteria of our review protocol. We identified two ongoing randomised clinical trials performed in Europe with data yet to be published. We retrieved a few observational studies (prospective and retrospective) with the searches for randomised clinical trials. They included a limited number of participants in whom laparoscopic and open liver resection was compared. Since these studies were non-randomised observational studies, the results for any adverse events are not included in the review as the risk of bias in such studies is high.

AUTHORS' CONCLUSIONS

No conclusions can be made at this time as no randomised clinical trials are available. In addition to the two ongoing randomised clinical trials for which results are expected to be published in the near future, well-designed, prospective, randomised clinical trials are needed in order to evaluate the benefits and harms of the laparoscopic procedure versus open liver resection.

Financial comparison of laparoscopic versus open hepatic resection using deviation-based cost modeling

BACKGROUND

There is a growing body of evidence suggesting the equivalence and in some cases superiority of laparoscopic liver resection versus open resection. Fewer data exist regarding the financial impact of laparoscopic liver resection.

METHODS

Retrospective review of 98 consecutive patients at a single institution from 2007 through 2011 undergoing first time hepatic resection was performed. Laparoscopic and open cases were compared primarily on OR and hospital charges. Deviation-based cost modeling and weighted average mean cost for the two procedures were used to determine both financial and clinical efficacy on the basis of differences in length of stay, complications, and charges.

RESULTS

There were 57 laparoscopic and 41 open cases included in the study. Right hepatectomy was the most common procedure performed in both the laparoscopic (n=23, 40.4%) and open (n=22, 53.7%) groups. Patients in the laparoscopic group were significantly more likely to have an "on course" postoperative hospitalization (73.7 vs. 26.8%; p<0.001), which translated into a WAMC of $58,401 for the laparoscopic cases and $69,728 for the open cases. In the subset of patients undergoing right hepatectomy, patients in the laparoscopic group remained more likely to have an on course hospitalization (61.2 vs. 31.8%; p=0.025). WAMC for the laparoscopic right hepatectomy group, however, was higher than the open group ($69,544 vs. $68,266).

CONCLUSIONS

The cost-effectiveness of laparoscopic hepatectomy appears to vary with the complexity of the procedure. Overall, laparoscopy offers a cost advantage; however, with more complex procedures such as right hepatectomy, higher up-front operating room charges offset the financial benefits of less complicated hospitalization.

Short- and long-term outcomes after laparoscopic and open hepatectomy for hepatocellular carcinoma: a global systematic review and meta-analysis

BACKGROUND

Laparoscopic hepatectomy (LH) has been proposed as a safe and feasible treatment option for liver diseases. However, the short- and long-term outcomes of LH versus open hepatectomy (OH) for hepatocellular carcinoma (HCC) have not been adequately assessed. Thus, as another means of surgical therapy for hepatocellular carcinoma (HCC), we assessed the feasibility of performing LH as the standard procedure for disease in the left lateral lobe and peripheral right segments for HCC in selected patients.

METHODS

Literature search included PubMed, Embase, Science Citation Index, SpringerLink, and secondary sources, from inception to March 2012, with no restrictions on languages or regions. The fixed-effects and random-effects models were used to measure the pooled estimates. The test of heterogeneity was performed by the Q statistic. Subgroup and sensitivity analyses were performed to explore heterogeneity between studies and to assess the effects of study quality.

RESULTS

A total of 1238 patients (LH 485, OH 753) from 15 studies were included. The pooled odds ratios for postoperative morbidity and incidence of negative surgical margin in LH were found to be 0.37 (95 % confidence interval [CI] 0.27-0.52; P < 0.01) and 1.63 (95 % CI 0.82-3.22; P = 0.16), respectively, compared with OH. Blood loss was significantly decreased in the LH (weighted mean difference -224.63; 95 % CI -384.87 to -64.39; P = 0.006). No significant difference was observed between the both groups for long-term outcomes of overall survival and recurrence-free survival.

CONCLUSIONS

In patients with solitary left lateral lobe/right peripheral subcapsular tumors treated with minor resection, this meta-analysis demonstrated that compared to OH, LH may have short-term advantages in terms of blood loss and postoperative morbidity for HCC. Both procedures have similar long-term outcomes. It may be time to consider changing the standard procedures for treatment of HCC in the left lateral lobe and peripheral subcapsular right segments in selected patients.

Laparoscopic resection of hepatocellular carcinoma

The current treatment of HCC is truly multidisciplinary. Notwithstanding, surgical management remains the gold standard which other therapies are compared to. Operative management is divided into transplantation and resection; the latter is further subdivided among open and laparoscopic approaches. Resection has become safer, remains superior to locoregional treatments, and can be a life-prolonging bridge to transplantation. The decision to pursue laparoscopic resection for HCC is driven by safety and a view toward the long-term management of both the malignancy and the underlying liver disease. For patients with a solitary HCC <5 cm in segments 2, 3, 4b, 5, and 6, no evidence of extrahepatic tumor burden, compensated liver disease, and the absence of significant portal hypertension, laparoscopy has an important role. Under these circumstances, resection can be performed with reduced mortality and morbidity and equivalent oncologic outcomes, disease-free survival, and overall survival when compared with similarly selected cirrhotic patients undergoing open resection. Blood loss and transfusion requirements are low, and laparoscopy itself does not expose the patient to complications and does not increase the risk of cancer recurrence or dissemination. Finally, because HCC recurrence remains high in the cirrhotic liver, treatment following surgical resection mandates routine surveillance and treatment by locoregional therapy, reresection, or transplantation as required-the latter two of which are facilitated by an initial laparoscopic resection.

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

AIM: To conduct a meta-analysis to determine the safety and efficacy of laparoscopic liver resection (LLR) and open liver resection (OLR) for hepatocellular carcinoma (HCC).

METHODS: PubMed (Medline), EMBASE and Science Citation Index Expanded and Cochrane Central Register of Controlled Trials in the Cochrane Library were searched systematically to identify relevant comparative studies reporting outcomes for both LLR and OLR for HCC between January 1992 and February 2012. Two authors independently assessed the trials for inclusion and extracted the data. Meta-analysis was performed using Review Manager Version 5.0 software (The Cochrane Collaboration, Oxford, United Kingdom). Pooled odds ratios (OR) or weighted mean differences (WMD) with 95%CI were calculated using either fixed effects (Mantel-Haenszel method) or random effects models (DerSimonian and Laird method). Evaluated endpoints were operative outcomes (operation time, intraoperative blood loss, blood transfusion requirement), postoperative outcomes (liver failure, cirrhotic decompensation/ascites, bile leakage, postoperative bleeding, pulmonary complications, intraabdominal abscess, mortality, hospital stay and oncologic outcomes (positive resection margins and tumor recurrence).

RESULTS: Fifteen eligible non-randomized studies were identified, out of which, 9 high-quality studies involving 550 patients were included, with 234 patients in the LLR group and 316 patients in the OLR group. LLR was associated with significantly lower intraoperative blood loss, based on six studies with 333 patients [WMD: -129.48 mL; 95%CI: -224.76-(-34.21) mL; P = 0.008]. Seven studies involving 416 patients were included to assess blood transfusion requirement between the two groups. The LLR group had lower blood transfusion requirement (OR: 0.49; 95%CI: 0.26-0.91; P = 0.02). While analyzing hospital stay, six studies with 333 patients were included. Patients in the LLR group were found to have shorter hospital stay [WMD: -3.19 d; 95%CI: -4.09-(-2.28) d; P < 0.00001] than their OLR counterpart. Seven studies including 416 patients were pooled together to estimate the odds of developing postoperative ascites in the patient groups. The LLR group appeared to have a lower incidence of postoperative ascites (OR: 0.32; 95%CI: 0.16-0.61; P = 0.0006) as compared with OLR patients. Similarly, fewer patients had liver failure in the LLR group than in the OLR group (OR: 0.15; 95%CI: 0.02-0.95; P = 0.04). However, no significant differences were found between the two approaches with regards to operation time [WMD: 4.69 min; 95%CI: -22.62-32 min; P = 0.74], bile leakage (OR: 0.55; 95%CI: 0.10-3.12; P = 0.50), postoperative bleeding (OR: 0.54; 95%CI: 0.20-1.45; P = 0.22), pulmonary complications (OR: 0.43; 95%CI: 0.18-1.04; P = 0.06), intra-abdominal abscesses (OR: 0.21; 95%CI: 0.01-4.53; P = 0.32), mortality (OR: 0.46; 95%CI: 0.14-1.51; P = 0.20), presence of positive resection margins (OR: 0.59; 95%CI: 0.21-1.62; P = 0.31) and tumor recurrence (OR: 0.95; 95%CI: 0.62-1.46; P = 0.81).

CONCLUSION: LLR appears to be a safe and feasible option for resection of HCC in selected patients based on current evidence. However, further appropriately designed randomized controlled trials should be undertaken to ascertain these findings.

Treatment of hepatocellular carcinoma: a systematic review

Hepatocellular carcinoma (HCC) is one of the most common malignancies, with an increasing incidence. With advances in surgical techniques and instrumentation and the development of molecular-target drugs, a number of potentially curative treatments have become available. Management of HCC patients depends on the stage of their tumor. Liver resection remains the first choice for very early-stage HCC, but it is being challenged by local ablative therapy. For early-stage HCC that meet the Milan criteria, liver transplantation still offers a better outcome; however, local ablative therapy can be a substitute when transplantation is not feasible. Local ablation is also used as a bridging therapy toward liver transplantation. HCC recurrence is the main obstacle to successful treatment, and there is currently no effective means of preventing or treating HCC recurrence. Transarterial therapy is considered suitable for intermediate-stage HCC, while sorafenib is recommended for advanced-stage HCC. This stage-based approach to therapy not only provides acceptable outcomes but also improves the quality of life of HCC patients. Because of the complexity of HCC, therapeutic approaches must be adapted according to the characteristics of each individual patient. This review discusses the current standards and trends in the treatment of HCC.

Laparoscopic versus open resection of colorectal liver metastasis

BACKGROUND

Findings have shown laparoscopic liver resection (LLR) to be feasible and safe, but the data in the literature regarding oncologic outcomes are scant. This study aimed to compare the perioperative and short-term oncologic outcomes between LLR and open resection of colorectal liver metastasis (CLM).

METHODS

Between January 2006 and April 2012, 40 patients underwent LLR of CLM. These patients were compared with a consecutive matched group of 40 patients who underwent open resection within the same period. Data were obtained from a prospective institutional review board (IRB)-approved database. Statistical analysis was performed using t test, Chi-square, and Kaplan-Meier survival.

RESULTS

The groups were similar in terms of age, gender, tumor size, number of tumors, and type of resections performed. The operative time was similar in the two groups, but the estimated blood loss was less in the LLR group than in the open resection group. The length of stay was shorter in the LLR group (3.7 vs 6.5 days; p < 0.001). The 2-year overall survival rate was 89 % for LLR and 81 % for open resection. The median disease-free survival time was 23 months in each group.

CONCLUSIONS

The findings suggest that LLR is associated with less blood loss and a shorter hospital stay than open resection for CLM. According to our short-term results, LLR is equivalent to open resection in terms of oncologic outcomes.

Laparoscopic or open liver resection? Let systematic review decide it

BACKGROUND

Laparoscopic liver resection is increasingly being used for the excision of benign and malignant hepatic lesions. The aim of this study was to perform meta-analysis on the compiled data from available observational studies.

METHODS

All the studies comparing laparoscopic versus open liver resections were searched on the available databases. Data were analyzed using Review Manager software version 5.0 (The Cochrane Collaboration, Software Update, Oxford, UK).

RESULTS

There was a total of 2,466 patients: 1,161 (47.1%) in the laparoscopic group and 1,305 (52.9%) in the open group. The laparoscopic group was associated with a reduced overall complication rate (odds ratio = .35; 95% confidence interval [CI], .28-.45; P < .001; heterogeneity (HG): P = .51), fewer positive resection margins for malignant tumor resections (odds ratio = .38; CI, .20-.76; P = .006; HG: P = .52) and a decrease in the number of patients requiring blood transfusion (odds ratio = .36; CI, .23-.74; P < .001; HG: P = .30).

CONCLUSIONS

Laparoscopic liver resection showed a reduced overall morbidity rate and favorable and comparable outcomes when compared with the open group. However, there is still a need for randomized controlled trials to compare laparoscopic versus open hepatic resection in benign and malignant lesions.

Long-term results of laparoscopic hepatectomy versus open hepatectomy for hepatocellular carcinoma: a case-matched analysis

BACKGROUND

Laparoscopic hepatectomy (LH) is established as a safe and feasible treatment option for liver tumors. However, whether the adoption of laparoscopic approach for malignant tumors, such as hepatocellular carcinoma (HCC), will compromise the long-term result is still unknown. This study was designed to evaluate the long-term results of LH compared with a cohort of case-matched open hepatectomy (OH).

METHODS

Thirty-three patients who underwent LH for HCC in our institution between June 2004 and March 2010 were recruited. A group of 50 patients who underwent OH for HCC during the same period was identified by matching to magnitude of operation, size of tumor, site of tumor, and the absence of concomitant local ablation or major procedure. The perioperative outcomes, disease recurrence, and survival of the two groups of patients were determined and compared.

RESULTS

LH resulted in less operative complications (6.1% vs. 24%, P = 0.033) and shorter median hospital stay (5 vs. 7 days, P < 0.0005) but required longer operative time compared with OH (225 vs. 195 min, P = 0.019). There was no difference between LH and OH in recurrence rate (45.5% vs. 38%, P = 0.499). The 1-, 3-, and 5-year overall survival were 86.9%, 81.8%, and 76% for LH and 98%, 80.6%, and 76.1% for OH respectively (P = 0.646). The 1-, 3-, and 5-year disease-free survival were 78.8%, 51%, and 45.3% for LH and 69.2%, 55.9%, and 55.9% for OH, respectively (P = 0.849).

CONCLUSIONS

Compared with OH, LH for HCC has similar long-term outcomes, but it has short-term advantages of less operative complications and shorter hospital stay.

Surgical and oncologic outcomes following laparoscopic versus open liver resection for hepatocellular carcinoma: A meta-analysis

AIM

  Laparoscopic hepatectomy has become a common method for treatment of hepatocellular carcinoma (HCC) nowadays, but the oncologic risks of laparoscopic liver resection for HCC are still under investigation. We performed a meta-analysis to quantitatively compare surgical and oncologic outcomes of patients with HCC undergoing laparoscopic versus open hepatectomy.

METHODS

  Systematic review and meta-analysis of studies comparing laparoscopic with open liver resection for HCC. Two authors independently assessed study quality and extracted data. All data were analyzed using RevMan 5.

RESULTS

  Ten studies comprising 627 patients were eligible for inclusion. The overall rate of conversion to open surgery was 6.6%. The laparoscopic group had significantly less blood loss by 223.17 mL (95% confidence interval [CI]: -331.81, -114.54; P < 0.0001), fewer need for transfusions (odds ratio [OR]: 0.42, 95% CI: 0.22, .079; P = 0.007), shorter hospital stay by 5.05 days (95% CI: -7.84, -2.25; P = 0.0004) and fewer postoperative complications (OR: 0.50; 95% CI: 0.32, 0.77; P = 0.002). No significant differences were found concerning surgery margin (weighted mean differences [WMD], 0.55; 95% CI: -0.71, 1.80; P = 0.39), resection margin positive rate (OR, 0.63; 95% CI: 0.25, 1.54; P = 0.31) and tumor recurrence (OR, 0.79; 95% CI: 0.49, 1.27; P = 0.33). In the 244 patients that underwent laparoscopic hepatectomy of all 10 studies included, no patients developed tumor recurrence at the site of resection margin, peritoneal dissemination or trocar-site metastases.

CONCLUSIONS

  On currently available evidence, laparoscopic resection appears not to affect oncologic outcomes and increase tumor recurrence. It also offers less blood loss, decreased rate of intraoperative transfusion and shorter lengths of hospital stay. Laparoscopic resection is a safe and feasible choice for selected patients with HCC.

Laparoscopic liver resection

More than 3,000 laparoscopic liver resections (LLR) are performed worldwide for benign disease, malignancy, and living donor hepatectomy. Minimally invasive hepatic resection approaches include pure laparoscopic, hand-assisted laparoscopic, and a laparoscopic-assisted open "hybrid" approach, where the operation is started laparoscopically to mobilize the liver and begin the dissection, followed by a small laparotomy for completion of the parenchymal transection. Surgeons should have an advanced understanding of hepatic anatomy, extensive experience in open liver surgery, and technical skill to control major vascular and biliary structures laparoscopically before embarking on LLR. Although there is no absolute size criterion, smaller, peripheral lesions (<5 cm) that lie far from major vessels and anticipated transection planes are most amenable to LLR. Although the majority of reported LLR are non-anatomic resections or segmentectomies, several surgical groups are now performing laparoscopic major hepatic resections with excellent safety profiles. Patient benefits from LLR include less operative blood loss, less postoperative pain and narcotic requirement, and a shorter length of hospital stay, with comparable postoperative morbidity and mortality to open liver resection. Comparison studies between LLR and open resection have revealed no differences in width of resection margins for malignant lesions or overall survival after resection for hepatocellular cancer or colorectal cancer liver metastases. Advantages of LLR for HCC in particular include avoidance of collateral vessel ligation, decreased postoperative hepatic insufficiency, and fewer postoperative adhesions, all of which are features that enhance subsequent liver transplantation.

Meta-analysis of trials comparing minimally-invasive and open liver resections for hepatocellular carcinoma

BACKGROUND

Recent literature suggests that minimally-invasive hepatectomy (MIH) for hepatocellular carcinoma (HCC) is associated with better perioperative results and similar oncologic outcomes compared to open hepatectomy (OH). However, previous reports have been limited by small sample size and single-institution design.

METHODS

To overcome these limitations, we performed a meta-analysis of studies comparing MIH and OH in patients with HCC using a random-effects model.

RESULTS

Nine eligible studies were identified that included 227 patients undergoing MIH and 363 undergoing OH. Patients were similar respect to age, gender, rates of cirrhosis, hepatitis C infection, tumour size, and American Society of Anesthesiology classification. The MIH group had lower rates of hepatitis B infection. There were no differences in type of resection (anatomic or non-anatomic), use of Pringle's maneuver, and operative time. Patients undergoing MIH had less blood loss [difference -217 mL; 95% confidence interval (CI), -314 to -121], lower rates of transfusion [odds ratio (OR), 0.38; 95% CI, 0.24 to 0.59], shorter postoperative stay (difference -5 days; 95% CI, -7.84 to -2.25), lower rates of positive margins (OR, 0.30; 95% CI, 0.12 to 0.69) and perioperative complications (OR, 0.45; 95% CI, 0.31 to 0.66). Survival outcomes were similar in the two groups.

CONCLUSIONS

Although patient selection might have influenced some of the observed outcomes, MIH was associated with decreased blood loss, transfusions, rates of positive resection margins, overall and specific morbidity, and hospital stay. Survival outcomes did not differ between MIH and OH, although further studies are needed to evaluate the impact of MIH on long-term results.

Laparoscopic vs. open liver resection for malignant liver disease. A systematic review

INTRODUCTION

Since the introduction of minimally invasive techniques, there is little agreement about use of laparoscopic surgery for malignant liver lesions as compared to open resection. We aim to analyse all available data comparing both these groups.

METHODS

All the studies that compared laparoscopic and open liver resections for malignant lesions were searched on various databases. Data were collected and analysed in Review Manager RevMan (version 5.0).

RESULTS

There were total of 10 studies (n = 700) that compared laparoscopic (296/700) and open (404/700) hepatic resections for malignant lesions. Laparoscopic group was associated with reduced number of patients requiring blood transfusion [Odds ratio 0.35 CI 0.20, 0.60 P<0.001 HG 0.85], decreased number of positive resection margin [Odds ratio 0.34 CI 0.16, P0.006 HG 0.73] and decrease in overall complication rate [Odds ratio 0.43, CI 0.26, 0.73 P0.002 HG 0.22]. Laparoscopic group was associated with less operative blood loss [WMD 162.6 ml CI -261.79, 73.45 P<0.001] and reduced hospital stay [WMD 4.28 days CI -6.33, -2.23 P<0.001]; however, there was significant heterogeneity [HG <0.001] between the studies for these parameters.

CONCLUSION

The laparoscopic group was associated with reduce overall complication rate, positive resection margins and number of patients requiring blood transfusion. There is still need for level I and II data to compare laparoscopic versus open hepatic resection in malignant lesions.

Meta-analysis of laparoscopic versus open resection for hepatocellular carcinoma

BACKGROUND

Laparoscopic liver resection (LLR) remains to be established as a safe and effective alternative to open liver resection (OLR) for hepatocellular carcinoma (HCC).

AIMS

The aim of this meta-analysis is to compare laparoscopic versus open resection for HCC with regard to perioperative and oncologic outcomes.

METHODS

A literature search was performed to identify comparative studies reporting outcomes for both laparoscopic and open resection for HCC. Pooled odds ratios (OR) and weighted mean differences (WMD with 95% confidence intervals (95% CI) were calculated using either the fixed effects model or random effects model.

RESULTS

Ten nonrandomized controlled studies matched the selection criteria and reported on 494 subjects, of whom 213 underwent LLR and 281 underwent OLR for HCC. Compared with the perioperative results of open surgery, reports on laparoscopic resection indicate potentially favourable outcomes in terms of operative blood loss (WMD: -160.57, 95% CI: -246.49 to -74.66), blood transfusion requirement (OR: 0.39, 95% CI: 0.18 to 0.86), postoperative morbidity (OR: 0.48, 95% CI: 0.29 to 0.78), and length of hospital stay (WMD: -5.53, 95% CI: -7.89 to -3.16). Concerning the oncologic outcomes, there was no difference between groups in surgical margin, overall survival and disease-free survival.

CONCLUSIONS

LLR for HCC is superior to the OLR in terms of its perioperative results and does not compromise the oncological outcomes. Therefore, LLR may be an alternative choice for treatment of HCC.

Laparoscopic liver resection for hepatocellular carcinoma

OBJECTIVE

To provide an updated review on the clinical experience in laparoscopic liver resection, specifically for hepatocellular carcinoma.

METHODS

A comprehensive literature search in MEDLINE was conducted for all English papers up to May 2010 on laparoscopic liver resection for hepatocellular carcinoma. Patient characteristics, perioperative results, and oncologic outcomes were compared and analysed.

RESULTS

We analysed 11 clinical studies involving 466 hepatocellular carcinoma patients treated with laparoscopic hepatectomy. Thirty-seven (9%) patients underwent major resection. Cirrhosis occurred in 62%. The mean operative time was 189.5 min, and the mean blood loss was 315.6 mL. Blood transfusion was required in 14.6% of patients. There were two operative deaths. Postoperative complications included bile leakage (1%), bleeding (2.9%), liver failure (5.1%), and ascites (6%). The 1-year, 3-year, and 5-year disease-free survival rates ranged from 60% to 90%, 50% to 64%, and 31% to 50%, respectively, and the corresponding overall survival rates ranged from 85% to 100%, 67% to 100%, and 50% to 97% respectively.

CONCLUSION

Laparoscopic liver resection for hepatocellular carcinoma appears to be safe and to achieve acceptable oncologic outcomes even in cirrhotic livers, but whether it is comparable to conventional open surgery needs to be evaluated in a randomized, controlled trial setting.

Liver resection for hepatocellular carcinoma: case-matched analysis of laparoscopic versus open resection

Purpose

To analyze the outcomes of laparoscopic liver resection compared with open liver resection in patients with hepatocellular carcinoma (HCC).

Methods

Between July 2005 and December 2009, 26 consecutive patients with HCC underwent a pure laparoscopic liver resection, and data from this group (laparoscopic liver resection group, L-group) were compared with a retrospective control group of 29 patients who underwent open liver resection for HCC (open liver resection group, O-group) during the same period. The two groups were matched in terms of demographic data, tumor size, degree of liver cirrhosis, American Society of Anesthesiology score, type of resection, and tumor location.

Results

Median operation time and the amount of intraoperative packed red blood cell transfusion in the L-group were 147.5 minutes and 0.35 units, respectively. The L-group revealed a shorter operation time (147.5 vs. 220.0 minutes, P = 0.031) than the O-group. No difference in perioperative morbidity or mortality rates was observed (3.8, 0 vs. 24.1%, 0%; P = 0.054, non-specific, respectively); the L-group was associated with a shorter hospital stay than the O-group (11.08 vs. 16.07 days, P = 0.034). After a mean follow-up of 23.9 months (range, 0.7 to 59.4 months), the 1-year disease-free survival rate was 84.6% in the L-group and 82.8% in the O-group (P = 0.673).

Conclusion

Laparoscopic liver resection for HCC is feasible and safe in selected patients and can produce good surgical results with a shorter postoperative hospital stay and similar outcomes in terms of perioperative morbidity, mortality, and disease-free survival than open resection.

Laparoscopic liver resection: an examination of our first 300 patients

BACKGROUND

Laparoscopic liver resection is a procedure in evolution. In the last decade it has evolved from a novel procedure to a standard part of the hepatic surgeon's armamentarium. Few data exist on the development of a laparoscopic resection program.

STUDY DESIGN

With IRB approval, a retrospective review of 300 consecutive laparoscopic liver resections was undertaken. To determine changing results and patterns of practice, the cohort was divided into 3 consecutive groups of 100 patients. Patient demographics, indications for operation, operative factors, and in-hospital outcomes were examined. Continuous variables were analyzed with the Kruskal-Wallis test; continuous variables were compared with Fisher's exact test. Univariate and multivariate analyses of major complications (≥grade 3) were performed using logistic regression.

RESULTS

Of the 300 patients, 173 (61.6%) were female, with a median age of 54 years. There were 133 (44.3%) major resections. The median number of segments resected increased (3 vs 2, p = 0.015), as did the percentage of repeat hepatectomies (13.0% vs 2.0%, p = 0.001). At the same time, median operative time decreased (2.25 vs 3.0 hours, p < 0.001).and estimated blood loss was similar (150 mL vs 150 mL, p = 0.635). Morbidity was similar (11% vs 14%, p = 0.300), as was mortality (1% vs 3%, p = 0.625).

CONCLUSIONS

Laparoscopic liver resection has evolved from a novel procedure to a vital technique in liver surgery. Our group has demonstrated the ability over time to perform more difficult resections with similar morbidity and decreased operative length.

Laparoscopic liver surgery: new frontiers

Laparoscopic liver resection (LHR) has shown classical advantages of minimally invasive surgery over open counterpart. In spite of introduction in early 1990's only few centres worldwide adapted LHR to routine practice. It was due to considerable technical challenges and uncertainty about oncologic outcomes. Surgical instrumentation and accumulation of surgical experience has largely enabled to solve many technical considerations. Intraoperative navigation options have also been improved. Consequently indications have been drastically expanded nearly reaching criteria equal to open liver resection in expert centres. Recent studies have verified oncologic integrity of LHR. However, mastering of LHR is still a quite demanding task limiting expansion of this patient friendly technique. This emphasizes the necessity of systematic training for laparoscopic liver surgery. This article reviews the state of the art of laparoscopic liver surgery lightening burning issues of research and clinical practice.

Laparoscopic liver resection in the treatment of hepatocellular carcinoma

Laparoscopic liver resection is an emerging technique in liver surgery. Although laparoscopy is well established for several abdominal procedures and is considered by some the preferred approach, laparoscopic hepatic resection has been introduced into clinical practice more widely since 2000. These procedures are performed only in experienced centers and only in a select group of patients. While initially performed only for benign hepatic lesions, the indications for laparoscopic resection have gradually broadened to encompass all kinds of malignant hepatic lesions, including hepatocellular carcinoma in patients with cirrhosis, for whom the advantages of the minimally invasive approach may be most evident.