Laparoscopic liver resection facilitates salvage liver transplantation for hepatocellular carcinoma

Is laparoscopic repeat hepatectomy feasible? A tri-institutional analysis

BACKGROUND

A laparoscopic approach has not been advocated for repeat hepatectomy on a large scale. This report analyzes the experience of 3 institutions pioneering laparoscopic repeat liver resection (LRLR). The aim of this study was to evaluate the feasibility, safety, oncologic integrity, and outcomes of LRLR.

STUDY DESIGN

All patients undergoing LRLR were identified. Since 1997, 76 LRLRs have been attempted. Operative indications were metastasis (n = 63), hepatocellular carcinoma (n = 3), and benign tumors (n = 10). All patients had 1 or more earlier liver resections (28 open, 44 laparoscopic), including 16 major resections (en bloc removal of 3 or more Couinaud segments).

RESULTS

Eight conversions (11%) to open resections (n = 7) or radiofrequency ablation (n = 1) were required due to technical difficulties or hemorrhage. LRLRs included 49 wedge or segmental resections and 19 major hepatectomies. Median blood loss and operative time were 300 mL and 180 minutes. Patients with previous open liver resection (group B) experienced more intraoperative blood loss and transfusion requirements than those with earlier laparoscopic resections (group A) (p = 0.02; p = 0.01, respectively). R0 resection was achieved in 58 of 64 (91%) patients with malignant tumor. The incidence of postoperative complications and duration of hospital stay were not statistically different between the 2 groups. Bile leakages developed in 5 (6.6%) patients, including 1 requiring reoperation. There was no perioperative death. Median tumor size was 25 mm (range 5 to 125 mm) and the median number of tumors was 2 (range 1 to 7). Median follow-up was 23.5 months (range 0 to 86 months). There was no port-site metastasis. The 3- and 5-year actuarial survivals for patients with colorectal metastases were 83% and 55%, respectively.

CONCLUSIONS

Laparoscopic repeat hepatic resections can be performed safely and with good results, particularly in patients with earlier laparoscopic resections.

Laparoscopic liver resection--current update

An increasing number of studies are reporting the outcomes and benefits of laparoscopic liver resection. This article reviews the literature with emphasis on a recent consensus conference on laparoscopic liver resection in 2008, the learning curve for laparoscopic liver surgery, laparoscopic major hepatectomies, oncologic outcomes of laparoscopic liver resection for hepatocellular carcinoma and colorectal cancer liver metastases, and the comparative benefits of laparoscopic versus open liver resection. Current evidence suggests that minimally invasive hepatic resection is safe and feasible with short-term benefits, no economic disadvantage, and no compromise to oncologic principles.

Laparoscopic hepatectomy for hepatocellular carcinoma: a European experience

BACKGROUND

Some series have suggested that laparoscopy is beneficial for resection of hepatocellular carcinoma. This has to be confirmed in larger series. The aim of this study was to analyze the results of 3 European surgical centers on laparoscopic liver resections for hepatocellular carcinoma.

STUDY DESIGN

Prospective databases of 3 European centers involved in the development of laparoscopic liver surgery were combined. Between 1998 and 2008, 163 liver resections for hepatocellular carcinoma were performed. Liver parenchyma was cirrhotic in 120 (73.6%) patients. Liver resection was anatomic in 107 (65.6%) patients and was a major resection (>or=3 segments) in 16 (9.8%). A totally laparoscopic approach was used in 155 (95.1%) patients.

RESULTS

Median surgical duration was 180 minutes. Median operative blood loss was 250 mL, and 16 (9.8%) patients received blood transfusion. Conversion to open surgery was required in 15 (9.2%) patients. Median tumor size was 3.6 cm and median surgical margin was 12 mm. Liver-specific and general complications occurred in 19 (11.6%) and 17 (10.4%) patients, respectively. Hospital length of stay was 7 days. A further analysis of early (n = 75) and recent (n = 88) experiences showed improved results in the latter group. Overall and recurrence-free survival rates at 1, 3, and 5 years were 92.6%, 68.7%, 64.9%, and 77.5%, 47.1%, 32.2%, respectively.

CONCLUSIONS

This study demonstrates that laparoscopic resection for hepatocellular carcinoma is feasible in selected patients, with good operative and oncologic results. Laparoscopy should be routinely considered in centers experienced in liver surgery and advanced laparoscopy.

Laparoscopic hand-assisted right hemihepatectomy by ultrasound-directed intrahepatic approach

BACKGROUND/PURPOSE

Laparoscopic hepatectomy is a promising option for patients affected by a liver mass, and the procedure is gaining popularity. Minor laparoscopic resections have been widely reported. In contrast, major laparoscopic hepatectomy has been performed in only a limited number of cases. Hand-assisted laparoscopic liver surgery has been advocated in order to improve liver exposure and vascular control and increase the safety of the procedure. Transparenchymal en-bloc transection of the right portal triad has been reported to be safe and useful in open surgery.

METHODS

We describe a personal technique for hand-assisted right hemihepatectomy. With ultrasound guidance, the right hepatic pedicle is isolated intrahepatically and transected en bloc with a single firing of an endostapler. Parenchymal transection is carried out with ultrasonically activated or vessel-sealing devices together with endostaplers.

RESULTS

The procedure was successfully accomplished in three patients. The Pringle maneuver was never performed. No intraoperative or postoperative complications occurred.

CONCLUSION

This study is the first to report a technique of right hemihepatectomy that combines hand-assisted laparoscopy and an ultrasound-guided intrahepatic approach. This technique may be a useful option to simplify the operation, reduce operative time, and increase the safety of the procedure.

Liver resection for transplantable hepatocellular carcinoma: long-term survival and role of secondary liver transplantation

BACKGROUND/PURPOSE

Liver transplantation (LT) is the best theoretical treatment of hepatocellular carcinoma (HCC) fulfilling the Milan criteria (TNM stages 1-2). However, LT is limited by organ availability and tumor progression on the waiting list. Liver resection (LR) may represent an alternative in these patients. The aim of this study is to report the results of LR in transplantable patients.

PATIENTS

From 1990 to 2007, 274 patients underwent liver resection for HCC. Sixty-seven (24%) met the Milan criteria on pathologic study of the specimen. Ten were TNM stage 1 and 57 stage 2 and all had chronic liver disease. There were 56 men and 11 women with a mean age of 63. LR included 12 major hepatectomies, 14 bisegmentectomies, 14 segmentectomies, and 27 nonanatomic resections. Thirty-seven resections were performed through a laparoscopic approach and there were only 8 open resections since 1998.

RESULTS

Three patients died postoperatively (4.5%), none after laparoscopic resection. Morbidity rate was 34%. After a mean follow-up of 4.8 years, 36 patients (54%) developed intrahepatic tumor recurrence. Twenty-eight (77%) were again transplantable of which 16 (44%) were transplanted. Two additional patients underwent pre-emptive LT (ie before recurrence). When considering 44 patients <65 years at the time of resection (ie upper age limit for LT), the rates of recurrence, transplantable recurrence, and intention to treat salvage transplantation (patients with transplantable recurrence actually transplanted) were 59%, 80%, and 61%, respectively. Overall and disease free 5-year survival rates were 72% and 44%, respectively. Survival was not influenced by TNM stage 1 or 2, AFP level, tumor differentiation, or the presence microscopic vascular invasion. Survival after salvage LT was 70% and 87% when calculated from the date of LT and LR, respectively.

CONCLUSION

LR for small solitary HCC in compensated cirrhosis yields an overall survival rate comparable to upfront LT. Despite a significant recurrence rate, close imaging monitoring after resection allows salvage LT in 61% of patients with recurrence on intention to treat analysis.

The learning curve in laparoscopic liver resection: improved feasibility and reproducibility

OBJECTIVE

To evaluate the "learning curve" effect on feasibility and reproducibility of laparoscopic liver resection (LLR).

SUMMARY BACKGROUND DATA

LLR is currently limited to few centers and to few procedures. Its reproducibility is still debated.

METHODS

: Patients undergoing LLR between 1996 and 2008 were included. Indications and type of hepatectomies were compared with those of open resections performed in the same period, considering 3 periods (1996-1999, 2000-2003, and 2004-2008). LLRs were divided into 3 equal groups of 58 cases and technical data and outcomes were compared. Risk-adjusted Cumulative Sum model was used for determining the learning curve based on the need for conversion.

RESULTS

Of 782, 174 (22.3%) patients underwent LLR. Proportion of LLR progressively increased (17.5%, 22.4%, and 24.2%), such as hepatocellular carcinoma (17.6%, 25.6%, and 39.4%, P < 0.05), colorectal metastases (0%, 6.5%, and 13.1%, P < 0.05), major hepatectomies (1.1%, 9.1%, 8.5%, P < 0.05), and right hepatectomies (0%, 13.2%, and 13.1%, P < 0.05). Comparing groups, results of LLR significantly improved in terms of conversion rate (15.5%, 10.3%, and 3.4%, P < 0.05), operative time (210, 180, and 150 minutes, P < 0.05), blood loss (300, 200, and 200 mL, P < 0.05), and morbidity (17.2%, 22.4%, and 3.4%, P < 0.05). Pedicle clamping was less used over time (77.6%, 62.1%, and 17.2%, P < 0.05) and for shorter durations (45, 30, and 20 minutes, P < 0.05). Having adjusted for case-mix, the Cumulative Sum analysis demonstrated a learning curve for laparoscopic hepatectomies of 60 cases.

CONCLUSION

A slow but constant evolution of LLR occurred: indications and magnitude of procedures increased and technical outcomes improved. The learning curve demonstrated in this study suggests that LLR is reproducible in liver units but specific training to advanced laparoscopy is required.

Laparoscopic resection for hepatocellular carcinoma: a matched-pair comparative study

BACKGROUND

Only a few series have demonstrated the safety of laparoscopic resection for hepatocellular carcinoma (HCC) and the benefits of this approach. Moreover, these studies reported mostly minor and nonanatomic hepatic resections. This report describes the results of a pair-matched comparative study between open and laparoscopic liver resections for HCC in a series of essentially anatomic resections.

METHODS

Patients were retrospectively matched in pairs for the following criteria: sex, age, American Society of Anesthesiology (ASA) score, severity of liver disease, tumor size, and type of resection. A total of 42 patients undergoing laparoscopy were compared with patients undergoing laparotomy during the same period. Surgeons from the authors' department not trained in laparoscopy performed open resections. Operative, postoperative, and oncologic outcomes were compared.

RESULTS

The mean duration of surgery was similar in the two groups. Significantly less bleeding was observed in the laparoscopic group (364.3 vs. 723.7 ml; p < 0.0001). Transfusion was required for four patients (9.5%) in the laparoscopic group and seven patients (16.7%) in the open surgery group (p = 0.51). Postoperative ascites was less frequent after laparoscopic resections (7.1 vs. 26.1%; p = 0.03). General morbidity was similar in the two groups (9.5 vs. 11.9%; p = 1.00). The mean hospital stay was significantly shorter for the patients undergoing laparoscopy (6.7 vs. 9.6 days; p < 0.0001). The surgical margin and local recurrence adjacent to the liver stump were not affected by laparoscopy. The overall postoperative survival rates in the laparoscopic group were 93.1% at 1 year, 74.4% at 3 years, and 59.5% at 5 years and, respectively, 81.8, 73, and 47.4% in the open surgery group (p = 0.25). The postoperative disease-free survival rates in the laparoscopic group were at 81.6% at 1 year, 60.9% at 3 years, and 45.6% at 5 years, respectively, 70.2, 54.3, and 37.2% in the open surgery group (p = 0.29).

CONCLUSIONS

Laparoscopic resection of HCC for selected patients gave a better postoperative outcome without oncologic consequences. Prospective trials are required to confirm these results.

Liver transplantation for HCC: its role: Eastern and Western perspectives

Liver transplantation (LT) is the only treatment that offers a chance of cure for hepatocellular carcinoma (HCC) and the underlying liver cirrhosis simultaneously, but the availability of liver grafts and the aggressiveness of tumor recurrence are critical limiting factors of LT for patients with HCC. In most Asian countries, the serious shortage of deceased donors and the strong demand for LT has lead to the development of living-donor LT (LDLT) as a practical alternative replacing deceased-donor LT (DDLT). Grafts in Western countries are issued from DDLT and graft allocations are under the responsibilities of state agencies which apply strict rules based on the MELD (model for end-stage liver disease) score. Considering that HCC recurrence is the most common cause of post-transplant patient death, recipient candidates should be prudently selected through objectively established criteria. Points in addition to the MELD score can be allotted to patients with HCC providing that the HCC remains within the Milan criteria. The increasing number of LT candidates with HCC results in increasing waiting periods, which necessitate the consideration of pretransplant treatment of HCC, including partial liver resection. Both specific Western units and some Asian major LDLT centers have challenged the Milan criteria. The eligibility criteria of both DDLT and LDLT for HCC are likely to be expanded more than before, but this still requires further qualified risk-benefit analyses. The development of new effective treatment modalities before LT and for HCC recurrence might expand the selection criteria further without incurring an increased recurrence rate.

Laparoscopic liver surgery: 8 years of multicenter Spanish register

BACKGROUND

To present the data of laparoscopy in liver surgery and to assess the real indications and outcomes of this kind of approach.

METHODS

From February 2000 to March 2008, a prospective study was performed on 182 patients from 15 Spanish surgical centres.

RESULTS

A total of 308 lesions was collected. The mean age was 57 years old, and 61.5% were female. Among patients with cystic lesions we found: 45 simple cysts, 19 policystic diseases, 12 hydatidic cysts and 2 cystoadenomas. Among solid lesions (n = 104), we found 34 patients with benign pathology (12 focal nodular hyperplasia, 10 adenomas, 7 haemangyomas and 5 other lesions) and 70 with malignant pathology (38 metastases, 29 hepatocellular carcinomas, 2 cholangiocarcinomas and 1 lymphoma). The global rate of conversion was 8.8%. The global morbidity rate was 14.8%, and 5 of them required re-intervention.

CONCLUSIONS

Nowadays there are strong criteria for patients being submitted to laparoscopy procedures based both on type and location features. The postoperative morbidity rate is low, also for hepatocellular carcinoma in cirrhotic liver. In case of malignant pathology, we think the use of ultrasonography is mandatory to obtain a free margin, which implies a long-term survival rate.

Laparoscopic liver resection-understanding its role in current practice: the Henri Mondor Hospital experience

OBJECTIVE

To report our complete experience with laparoscopic liver resection (LLR) to understand what role it may play in the broader context of liver surgery.

BACKGROUND

The goal of LLR is to extend the benefits of the laparoscopic approach without compromising the fundamental principles of open liver surgery. LLR, however, presents unique technical challenges and its evaluation is made difficult by the restricted indications for this approach, the few centers world-wide experienced in the technique, and the heterogeneity of procedures and pathologies involved.

METHODS

Retrospective analysis of a prospectively maintained database of liver resections from a unit with a comprehensive liver program, including resection and transplantation.

RESULTS

There were 166 laparoscopic liver resections between May 23, 1996 and December 31, 2007, including 100 (60%) for malignant pathology (64 HCC, 3 cholangiocarcinoma, 33 hepatic metastases) and 66 for benign pathology (adenoma, 23; FNH, 19; cystic, 17; other, 7). Numbers of resections for benign indications remained stable over time whereas those for malignant indications increased. There were 31 major resections, 56 left lateral sectionectomies, 28 segmentectomies, and 51 tumorectomies. There was 0% mortality and 15.1% morbidity. Median blood loss was 200 mL, 9 patients (5.4%) required transfusion, and median operating time was 180 minutes. Left lateral sectionectomies demonstrated reduced bleeding (median, 175 vs. 300 mL, P = 0.0015) and faster operating time (median, 170 vs. 180 minutes, P = 0.0265). In the second half of the experience, there was reduced bleeding (median, 200 vs. 300 mL, P = 0.0022) and a lower conversion rate (2.4% vs. 16.9%, P = 0.0015).

CONCLUSIONS

Good patient selection and refined surgical technique are the keys to successful LLR. The indications for resection of asymptomatic benign lesions should not be increased because the laparoscopic approach is available. Hepatocellular carcinomas (HCCs) are more likely to be suitable to a laparoscopic approach than colorectal liver metastases. Left lateral sectionectomy and limited resection of solitary peripheral lesions are particularly suitable while hemihepatectomies remain challenging procedures. LLR requires an ongoing robust audit to identify any emerging problems.

Laparoscopic liver resection: a systematic review

BACKGROUND

Outcomes of laparoscopic liver resection (LLR) are not clarified. The objective of this article is to depict the state of the art of LLR by means of a systematic review of the literature.

METHODS

Studies about LLR published before September 2008 were identified and their results summarized.

RESULTS

Indications for laparoscopic hepatectomy do not differ from those for open surgery. Technical feasibility is the only limiting factor. Bleeding is the major intraoperative concern, but, if managed by an expert surgeon, do not worsen outcomes. Hand assistance can be useful in selected cases to avoid conversion. Patient selection must take both tumor location and size into consideration. Potentially good candidates are patients with peripheral lesions requiring limited hepatectomy or left lateral sectionectomy; their outcomes, including reduced blood loss, morbidity, and hospital stay, are better than those of their laparotomic counterparts. The same advantages have been observed in cirrhotics. Laparoscopic major hepatectomies and resections of postero-superior segments need further evaluation. The results of LLR in cancer patients seem to be similar to those obtained with the laparotomic approach, especially in cases of hepatocellular carcinoma, but further analysis is required.

CONCLUSIONS

Laparoscopic liver resection is safe and feasible. The laparoscopic approach can be recommended for peripheral lesions requiring limited hepatectomy or left lateral sectionectomy. Preliminary oncological results suggest non-inferiority of laparoscopic to laparotomic procedures.