Laparoscopic vs Open Surgery for Colorectal Liver Metastases

Minimally Invasive Approach Provides Oncological Benefit in Patients with High Risk of Very Early Recurrence (VER) After Surgery for Intrahepatic Cholangiocarcinoma (iCCA)

BACKGROUND

Surgery for intrahepatic cholangiocarcinoma (iCCA) is jeopardized by significant risk of early recurrence (≤ 6 months). The aim of the present study is to analyze the oncological benefit provided by laparoscopic over open approach for iCCA in patients with high risk of very early recurrence (VER).

MATERIALS AND METHODS

A total of 532 liver resections (LR) were performed for iCCA [265 by minimally invasive surgery (MIS) and 267 with open approach, matched through a 1:1 propensity score] and stratified using the postoperative prediction model of VER. Outcomes were compared between open and laparoscopic approaches, specifically evaluating oncological benefit.

RESULTS

The percentage of patients with high risk of VER was similar (32.7% in the laparoscopic group and 35.3% in the open group, pNS). The number of retrieved nodes as well as the rate and depth of negative resection margins were comparable between laparoscopic and open. The surgery-adjuvant treatment interval was shorter in laparoscopic patients in the overall series, as well in the subgroup of high risk of VER. The rate of patients starting adjuvant treatments within 2 months from surgery was higher in laparoscopic group compared with open group. In VER high-risk group both disease-free survival (DFS) and overall survival (OS) were significantly improved in MIS compared with open group (p = 0.032 and p = 0.026, respectively).

CONCLUSIONS

In patients with high risk of VER, laparoscopy translates into an advantage in terms of recurrence-free survival, likely related to lower biological impact of surgery, together with a shorter interval between surgery and start of adjuvant treatments, even allowing for a higher number of patients to start adjuvant therapies within 2 months from resection.

Minimal Invasive Versus Open Surgery for Colorectal Liver Metastases: A Multicenter German StuDoQ|Liver Registry-Based Cohort Analysis in Germany

Objective

To compare the outcome of minimally invasive liver surgery (MILS) to open liver surgery (OLS) for resection of colorectal liver metastases (CRLM) on a nationwide level.

Background

Colorectal cancer is the third most common malignancy worldwide. Up to 50% of all patients with colorectal cancer develop CRLM. MILS represents an attractive alternative to OLS for treatment of CRLM.

Methods

Retrospective cohort study using the prospectively recorded German Quality management registry for liver surgery. Propensity-score matching was performed to account for variance in the extent of resection and patient demographics.

Results

In total, 1037 patients underwent liver resection for CRLM from 2019 to 2021. MILS was performed in 31%. Operative time was significantly longer in MILS (234 vs 222 minutes, P = 0.02) compared with OLS. After MILS, median length of hospital stay (LOS) was significantly shorter (7 vs 10 days; P < 0.001). Despite 76% of major resections being OLS, postoperative complications and 90-day morbidity and mortality did not differ. The Pringle maneuver was more frequently used in MILS (48% vs 40%, P = 0.048). After propensity-score matching for age, body mass index, Eastern Cooperative Oncology Group, and extent of resection, LOS remained shorter in the MILS cohort (6 vs 10 days, P < 0.001) and operative time did not differ significantly (P = 0.2).

Conclusion

MILS is not the standard for resection of CRLM in Germany. Drawbacks, such as a longer operative time remain. However, if technically possible, MILS is a reasonable alternative to OLS for resection of CRLM, with comparable postoperative complications, reduced LOS, and equal oncological radicality.

Minimally invasive vs. open approach to the simultaneous treatment of colorectal tumors with synchronous liver metastasis: a single center, propensity-score matched analysis from Mayo clinic

BACKGROUND

Open combined resections of colorectal primary tumors and synchronous liver metastases have become common in selected cases. However, evidences favoring a minimally invasive (MIS) approach are still limited. The aim of this study is to evaluate the outcomes of MIS vs. open synchronous liver and colorectal resections.

METHODS

384 cases of synchronous colorectal and liver resections performed at one institution were identified during the study period. MIS vs open approach were compared after a propensity score matching; surgical outcomes were analyzed.

RESULTS

MIS cases featured longer operative time (399 vs 300 min, p < 0.001), fewer blood loss (200 vs 500 ml, p = 0.003), and shorter hospitalization (median LOS 4 vs 6 days, p = 0.001). No difference was observed between the two groups for use of Pringle maneuver (p = 0.083), intraoperative blood transfusion (p = 0.061), achievement of negative colorectal (p = 0.176) and liver margins (p = 1.000), postoperative complications (p = 1.000) and significant (Clavien-Dindo ≥ 3a) complications (p = 0.817), delay of adjuvant therapy due to complications (p = 0.555), 30- and 90-day mortality.

CONCLUSION

Synchronous colorectal and liver metastases resections via a minimally-invasive approach in high-volume centers with appropriate expertise result in significantly lower blood loss and length of stay despite longer operative time in comparison to open, with no oncological inferiority.

Comparing Outcomes of Minimally Invasive and Open Hepatectomy for Primary Liver Malignancies in Patients with Low-MELD Cirrhosis

INTRODUCTION

Cirrhotic patients with primary liver cancer may undergo curative-intent resection when selected appropriately. Patients with T1 tumors and low-MELD are generally referred for resection. We aim to evaluate whether minimally invasive hepatectomy (MIH) is associated with improved outcomes versus open hepatectomy (OH).

METHODS

NSQIP hepatectomy database 2014-2021 was used to select patients with T1 Hepatocellular Carcinoma (HCC) or Intra-hepatic Cholangiocarcionoma (IHCC) and low-MELD cirrhosis (MELD ≤ 10) who underwent partial hepatectomy. Propensity score matching was applied between OH and MIH patients, and 30-day postoperative outcomes were compared. Multivariable regression was used to identify predictors of post-hepatectomy liver failure (PHLF) in the selected population.

RESULTS

There were 922 patients: 494 (53.6%) OH, 372 (40.3%) MIH, and 56 (6.1%) began MIH converted to OH (analyzed with the OH cohort). We matched 354 pairs of patients with an adequate balance between the groups. MIH was associated with lower rates of bile leak (HR 0.37 [0.19-0.72)], PHLF (HR 0.36 [0.15-0.86]), collections requiring drainage (HR 0.30 [0.15-0.63]), postoperative transfusion (HR 0.36 [0.21-0.61]), major (HR 0.45 [0.27-0.77]), and overall morbidity (HR 0.44 [0.31-0.63]), and a two-day shorter median hospitalization (3 vs. 5 days; HR 0.61 [0.45-0.82]). No difference was noted in operative time, wound, respiratory, and septic complications, or mortality. Regression analysis identified ascites, prior portal vein embolization (PVE), additional hepatectomies, Pringle's maneuver, and OH (vs. MIH) as independent predictors of PHLF.

CONCLUSION

MIH for early-stage HCC/IHCC in low-MELD cirrhotic patients was associated with improved postoperative outcomes over OH. These findings suggest that MIH should be considered an acceptable approach in this population of patients.

Development and Validation of a Radiomics Nomogram for Liver Metastases Originating from Gastric and Colorectal Cancer

The origin of metastatic liver tumours (arising from gastric or colorectal sources) is closely linked to treatment choices and survival prospects. However, in some instances, the primary lesion remains elusive even after an exhaustive diagnostic investigation. Consequently, we have devised and validated a radiomics nomogram for ascertaining the primary origin of liver metastases stemming from gastric cancer (GCLMs) and colorectal cancer (CCLMs). This retrospective study encompassed patients diagnosed with either GCLMs or CCLMs, comprising a total of 277 GCLM cases and 278 CCLM cases. Radiomic characteristics were derived from venous phase computed tomography (CT) scans, and a radiomics signature (RS) was computed. Multivariable regression analysis demonstrated that gender (OR = 3.457; 95% CI: 2.102-5.684; p < 0.001), haemoglobin levels (OR = 0.976; 95% CI: 0.967-0.986; p < 0.001), carcinoembryonic antigen (CEA) levels (OR = 0.500; 95% CI: 0.307-0.814; p = 0.005), and RS (OR = 2.147; 95% CI: 1.127-4.091; p = 0.020) exhibited independent associations with GCLMs as compared to CCLMs. The nomogram, combining RS with clinical variables, demonstrated strong discriminatory power in both the training (AUC = 0.71) and validation (AUC = 0.78) cohorts. The calibration curve, decision curve analysis, and clinical impact curves revealed the clinical utility of this nomogram and substantiated its enhanced diagnostic performance.

Microwave-activated Cu-doped zirconium metal-organic framework for a highly effective combination of microwave dynamic and thermal therapy

Percutaneous microwave ablation (PMA) is a thermoablative method used as a minimally invasive treatment for liver cancer. However, the application of PMA is limited by its insufficient ROS generation efficiency and thermal effects. Herein, a new microwave-activated Cu-doped zirconium metal-organic framework (MOF) (CuZr MOF) used for enhanced PMA has a significantly improved microwave sensitizing effect. Owing to the strong inelastic collisions between ions confined in numerous micropores, CuZr MOF has strong microwave sensitivity and high thermal conversion efficiency, which can significantly improve microwave thermal therapy (MTT). Moreover, because of the existence of Cu2+ ions, a further benefit of CuZr MOF is their Fenton-like activity, in particular, microwaves used as an excitation source for microwave dynamic therapy (MDT) can improve the Fenton-like reaction to maximize the synergistic effectiveness of cancer therapy. Importantly, CuZr MOF can inhibit the production of heat shock proteins (HSPs) by producing abundant ROS to enhance tumor destruction. Mechanistically, we found that CuZr MOF + MW treatment modulates ferroptosis-mediated tumor cell death by targeting the HMOX1/GPX4 axis. In summary, this study develops a novel CuZr MOF microwave sensitizer with great potential for synergistic treatment of liver cancer by MTT and MDT.

Robo-Lap Approach Optimizes Intraoperative Outcomes in Robotic Left and Right Hepatectomy

Background

The aim of the present study is to evaluate the possible advantages of the Robo-Lap (parenchymal transection by laparoscopic ultrasonic dissector and robotic bipolar forceps and scissors) compared with pure robotic technique (parenchymal transection by use of robotic bipolar forceps and scissors) in major anatomical liver resections with specific focus on intraoperative outcomes.

Methods

Major liver resections performed by robotic approach between February 1, 2021 and March 31, 2023 were stratified into two groups according to the approach used to address the phase of liver transection; Pure Robotic Group (n = 21) versus Robo-Lap Group (n = 48). The two groups were compared in terms of intra- and postoperative outcomes and in terms of rate of achievement of intraoperative textbook outcomes.

Results

Conversion rate was similar between the two groups while incidence of adverse intraoperative events (according to Satava classification) was higher in the Pure Robotic compared with the Robo-Lap group (85.7% vs 39.6%, p < 0.001). Time to perform parenchymal transection was significantly shorter in the Robo-Lap group (180 min) compared with the Pure Robotic Group (240 min), p = 0.003. Intraoperative textbook outcomes were achieved in a lower proportion of patients in the Pure Robotic compared with the Robo-Lap group.

Conclusion

Outcomes of the present study suggest a favorable role of the Robo-Lap approach in robotic major resections as it allows an improvement of the intraoperative results, a greater probability of an uneventful conduction of the procedure, and therefore, better management of the operating room time.

Implementation and Outcome of Robotic Liver Surgery in the Netherlands: A Nationwide Analysis

OBJECTIVE

To determine the nationwide implementation and surgical outcome of minor and major robotic liver surgery (RLS) and assess the first phase of implementation of RLS during the learning curve.

BACKGROUND

RLS may be a valuable alternative to laparoscopic liver surgery. Nationwide population-based studies with data on implementation and outcome of RLS are lacking.

METHODS

Multicenter retrospective cohort study including consecutive patients who underwent RLS for all indications in 9 Dutch centers (August 2014-March 2021). Data on all liver resections were obtained from the mandatory nationwide Dutch Hepato Biliary Audit (DHBA) including data from all 27 centers for liver surgery in the Netherlands. Outcomes were stratified for minor, technically major, and anatomically major RLS. Learning curve effect was assessed using cumulative sum analysis for blood loss.

RESULTS

Of 9437 liver resections, 400 were RLS (4.2%) procedures including 207 minor (52.2%), 141 technically major (35.3%), and 52 anatomically major (13%). The nationwide use of RLS increased from 0.2% in 2014 to 11.9% in 2020. The proportion of RLS among all minimally invasive liver resections increased from 2% to 28%. Median blood loss was 150 mL (interquartile range 50-350 mL] and the conversion rate 6.3% (n=25). The rate of Clavien-Dindo grade ≥III complications was 7.0% (n=27), median length of hospital stay 4 days (interquartile range 2-5) and 30-day/in-hospital mortality 0.8% (n=3). The R0 resection rate was 83.2% (n=263). Cumulative sum analysis for blood loss found a learning curve of at least 33 major RLS procedures.

CONCLUSIONS

The nationwide use of RLS in the Netherlands has increased rapidly with currently one-tenth of all liver resections and one-fourth of all minimally invasive liver resections being performed robotically. Although surgical outcomes of RLS in selected patient seem favorable, future prospective studies should determine its added value.

The Long-Term Outcome of Laparoscopic Resection for Perihilar Cholangiocarcinoma Compared with the Open Approach: A Real-World Multicentric Analysis

OBJECTIVE

The aim of this study was to compare the short- and long-term outcomes of laparoscopic surgery (LS) and open surgery (OP) for perihilar cholangiocarcinoma (PHC) using a large real-world dataset in China.

METHODS

Data of patients with PHC who underwent LS and OP from January 2013 to October 2018, across 10 centers in China, were extracted from medical records. A comparative analysis was performed before and after propensity score matching (PSM) in the LS and OP groups and within the study subgroups. The Cox proportional hazards mixed-effects model was applied to estimate the risk factors for mortality, with center and year of operation as random effects.

RESULTS

A total of 467 patients with PHC were included, of whom 161 underwent LS and 306 underwent OP. Postoperative morbidity, such as hemorrhage, biliary fistula, abdominal abscess, and hepatic insufficiency, was similar between the LS and OP groups. The median overall survival (OS) was longer in the LS group than in the OP group (NA vs. 22 months; hazard ratio [HR] 1.19, 95% confidence interval [CI] 1.02-1.39, p = 0.024). Among the matched datasets, OS was comparable between the LS and OP groups (NA vs. 35 months; HR 0.99, 95% CI 0.77-1.26, p = 0.915). The mixed-effect model identified that the surgical method was not associated with long-term outcomes and that LS and OP provided similar oncological outcomes.

CONCLUSIONS

Considering the comparable long-term prognosis and short-term outcomes of LS and OP, LS could be a technically feasible surgical method for PHC patients with all Bismuth-Corlett types of PHC.

Real-time administration of indocyanine green in combination with computer vision and artificial intelligence for the identification and delineation of colorectal liver metastases

Introduction

Fluorescence guided surgery for the identification of colorectal liver metastases (CRLM) can be better with low specificity and antecedent dosing impracticalities limiting indocyanine green (ICG) usefulness currently. We investigated the application of artificial intelligence methods (AIM) to demonstrate and characterise CLRMs based on dynamic signalling immediately following intraoperative ICG administration.

Methods

Twenty-five patients with liver surface lesions (24 CRLM and 1 benign cyst) undergoing open/laparoscopic/robotic procedures were studied. ICG (0.05 mg/kg) was administered with near-infrared recording of fluorescence perfusion. User-selected region-of-interest (ROI) perfusion profiles were generated, milestones relating to ICG inflow/outflow extracted and used to train a machine learning (ML) classifier. 2D heatmaps were constructed in a subset using AIM to depict whole screen imaging based on dynamic tissue-ICG interaction. Fluorescence appearances were also assessed microscopically (using H&E and fresh-frozen preparations) to provide tissue-level explainability of such methods.

Results

The ML algorithm correctly classified 97.2 % of CRLM ROIs (n = 132) and all benign lesion ROIs (n = 6) within 90-s of ICG administration following initial mathematical curve analysis identifying ICG inflow/outflow differentials between healthy liver and CRLMs. Time-fluorescence plots extracted for each pixel in 10 lesions enabled creation of 2D characterising heatmaps using flow parameters and through unsupervised ML. Microscopy confirmed statistically less CLRM fluorescence vs adjacent liver (mean ± std deviation signal/area 2.46 ± 9.56 vs 507.43 ± 160.82 respectively p < 0.001) with H&E diminishing ICG signal (n = 4).

Conclusion

ML accurately identifies CRLMs from surrounding liver tissue enabling representative 2D mapping of such lesions from their fluorescence perfusion patterns using AIM. This may assist in reducing positive margin rates at metastatectomy and in identifying unexpected/occult malignancies.

Intentional R1 resection of liver metastases: A new treatment paradigm for patients with advanced colorectal cancer based on a propensity score-Matched case-control analysis

BACKGROUND

Clinical outcomes of colorectal cancer (CRC) patients after an incomplete microscopic (R1) resection of liver metastases may not differ from those following a microscopically margin negative (R0) resection, when the latest is not feasible because of anatomic issues. We aimed at comparing the clinical outcomes of CRC patients with an intentional R1 or with a R0 resection of liver metastases.

METHODS

All patients with advanced in CRC and liver metastases consecutively treated by liver resection between February 2005 and January 2019 at in the department of Digestive and Hepatobiliary Surgery of Henri Mondor University Hospital (Créteil, France) were included in this retrospective case-control study. Overall survival (OS) and event-free survival (EFS) were compared between patients who underwent an intentional (pre-operative decision) R1 resection (iR1) to those who had a R0 resection of liver metastases. To account for confounding, comparison between the 2 groups was performed after adjustment using propensity score analysis.

RESULTS

Twenty-six CRC patients treated by iR1 resection of liver metastases were compared to 98 patients treated by R0 resection. Median OS reached 39 months [95% confidence interval (CI): 25-67] and 63 months [95% CI: 52-76] in the iR1 and R0 groups, respectively. After adjustment by inverse probability of treatment weighting, patients' OS and EFS did not differ significantly between the iR1 and R0 groups (hazard ratio (HR): 1.19 [0.54-2.62] and 1.67 [0.93-3.03]), respectively.

CONCLUSION

iR1 resection of liver metastases in advanced CRC patients is an acceptable therapeutic strategy, when R0 resection is not feasible.

Recent Advances in Minimally Invasive Liver Resection for Colorectal Cancer Liver Metastases-A Review

Minimally invasive surgical (MIS) approaches to liver resection have been increasingly adopted into use for surgery on colorectal cancer liver metastases. The purpose of this review is to evaluate the outcomes when comparing laparoscopic liver resection (LLR), robotic liver resection (RLR), and open liver resection (OLR) for colorectal cancer liver metastases (CRLM) in 39 studies (2009-2022) that include a case-matched series, propensity score analyses, and three randomized clinical trials. LLR is associated with less intraoperative blood loss and shorter hospital stay compared with OLR. LLR can be performed with comparable operative time. LLR has similar rates of perioperative complications and mortality as OLR. There were no significant differences in 5-year overall or disease-free survival between approaches. Robotic liver resection (RLR) has comparable perioperative safety to LLR and may improve rates of R0 resection in certain patients. Finally, MIS approaches to the hepatic resection of CRLM reduce the time from liver resection to initiation of adjuvant chemotherapy. Thus, MIS liver surgery should be considered in the array of options for patients with CRLM, though thoughtful patient selection and surgeon experience should be part of that decision.

Diagnostic value of an enhanced MRI combined with serum CEA, CA19-9, CA125 and CA72-4 in the liver metastasis of colorectal cancer

OBJECTIVE

This paper aims to explore the diagnostic value of enhanced magnetic resonance imaging (MRI) combined with a carcinoembryonic antigen (CEA) and carbohydrate antigen in terms of the liver metastasis of colorectal cancer.

METHODS

A total of 167 colorectal cancer patients with liver metastasis and 167 colorectal cancer patients without liver metastasis were selected as the subjects. An automatic electrochemiluminescence analyser was then used to detect the tumour markers CEA, CA19-9, CA125 and CA72-4. The consistency between the MRI examination and clinical pathological examination was also analysed, and the sensitivity, specificity and positive and negative predictive values of various combined detection methods were compared.

RESULTS

The abnormal rates of CEA, CA19-9, CA125 and CA72-4 in the two groups were statistically significant (P < 0.05), while the results of the enhanced MRI and clinicopathological examination for liver metastasis in patients with colon cancer were largely consistent (Kappa coefficient = 0.788, P < 0.000). However, the two methods were inconsistent. The false positive rate of the enhanced MRI examination was 15.3%, while the false negative rate was 6.0%. The specificity (94.61%), positive predictive value (92.68%) and positive likelihood ratio (12.67%) were the highest for the MRI combined with serial CEA, while the sensitivity (98.80%) and negative predictive value (97.22%) were the highest with the MRI combined with parallel CEA, and this combination returned the lowest negative likelihood ratio (0.03).

CONCLUSION

The combination of MRI and CEA excludes non-metastatic patients and identifies colorectal liver metastasis cancer patients. Overall, it has a higher diagnostic value.

A Comparison between Open and Minimally Invasive Techniques for the Resection of Colorectal Liver Metastasis

The liver is the most common site of colorectal cancer metastasis. Liver surgery is a cornerstone in treatment, with progressive expansion of minimally invasive surgery (MIS). This study aims to compare short- and long-term outcomes of open surgery and MIS for the treatment of colorectal adenocarcinoma liver metastasis during the first three years of increasing caseload and implementation of MIS use in liver surgery. All patients treated between November 2018 and August 2021 at Careggi Teaching Hospital in Florence, Italy, were prospectively entered into a database and retrospectively reviewed. Fifty-one patients were resected (41 open, 10 MIS). Considering that patients with a significantly higher number of lesions underwent open surgery and operative results were similar, postoperative morbidity rate and length of hospital stay were significantly higher in the open group. No differences were found in the pathological specimen. The postoperative mortality rate was 2%. Mean overall survival and disease-free survival were 46 months (95% CI 42-50) and 22 months (95% CI 15.6-29), respectively. The use of minimally invasive techniques in liver surgery is safe and feasible if surgeons have adequate expertise. MIS and parenchymal sparing resections should be preferred whenever technically feasible.

Minimally invasive versus open hepatectomy for the resection of colorectal liver metastases: a systematic review and meta-analysis

BACKGROUND

While surgical resection has a demonstrated utility for patients with colorectal liver metastases (CRLM), it is unclear whether minimally invasive surgery (MIS) or an open approach should be used. This review sought to assess the efficacy and safety of MIS versus open hepatectomy for isolated, resectable CRLM when performed separately from (Key Question (KQ) 1) or simultaneously with (KQ2) the resection of the primary tumor.

METHODS

PubMed, Embase, Google Scholar, Cochrane CENTRAL, International Clinical Trials Registry Platform (ICTRP), and ClinicalTrials.gov databases were searched to identify both randomized controlled trials (RCTs) and non-randomized comparative studies published during January 2000-September 2020. Two independent reviewers screened literature for eligibility, extracted data from included studies, and assessed internal validity using the Cochrane Risk of Bias 2.0 Tool and the Newcastle-Ottawa Scale. A random-effects meta-analysis was performed using risk ratios (RR) and mean differences (MD).

RESULTS

From 2304 publications, 35 studies were included for meta-analysis. For staged resections, three RCTs and 20 observational studies were included. Data from RCTs indicated MIS having similar disease-free survival (DFS) at 1-year (RR 1.03, 95%CI 0.70-1.50), overall survival (OS) at 5-years (RR 1.04, 95%CI 0.84-1.28), fewer complications of Clavien-Dindo Grade III (RR 0.62, 95%CI 0.38-1.00), and shorter hospital length of stay (LOS) (MD -6.6 days, 95%CI -10.2, -3.0). For simultaneous resections, 12 observational studies were included. There was no evidence of a difference between MIS and the open group for DFS-1-year, OS-5-year, complications, R0 resections, blood transfusions, along with lower blood loss (MD -177.35 mL, 95%CI -273.17, -81.53) and shorter LOS (MD -3.0 days, 95%CI -3.82, -2.17).

CONCLUSIONS

Current evidence regarding the optimal approach for CRLM resection demonstrates similar oncologic outcomes between MIS and open techniques, however MIS hepatectomy had a shorter LOS, lower blood loss and complication rate, for both staged and simultaneous resections.

Need for nursing care after laparoscopic and open colorectal cancer surgery: a claims data analysis in German primary care

Purpose

Our study analyzes the influence of minimally invasive vs. open surgery on the postoperative need for nursing care in patients with colorectal carcinoma. Colorectal cancer is an age-related disease, and oncologic surgery is increasingly performed in elderly patients. Long-term effects of the procedural choice on patients’ self-sufficiency and autonomy have not been scientifically addressed so far.

Methods

Multivariable logistic regression models based on claims data from a statutory health insurer (AOK, Baden-Württemberg, Germany) were applied to assess potential risk factors for assignment patients to a nursing care level, a German scale to categorize individual need for nursing care, at 12 and 36 months after colorectal cancer surgery.

Results

A total of 3996 patients were eligible to be included in the analysis. At 36 months postoperatively, 44 of 427 (10.3%) patients after minimally invasive colon cancer surgery and 231 of 1287 (17.9%) patients after open procedure were newly graded into a nursing care level (OR = 0.62, 95%CI = 0.44–0.90, p = 0.010). Thirty-four of 251 (13.5%) patients receiving minimally invasive rectal cancer surgery compared to 142 of 602 (23.6%) patients after open approach were newly assigned to a nursing care level (OR = 0.53, 95%CI = 0.34–0.81, p = 0.003).

Conclusions

Laparoscopically assisted resection of colorectal cancer seems to be superior in preserving physical autonomy of elderly patients with colorectal cancer.

Have we really understood when the efforts of laparoscopic liver resection are justified?-a complexity-based appraisal of the differential benefit

Background

The implementation of minimally invasive liver resection surgery (MILS) programs starts from procedures with a low degree of technical difficulty. Data regarding the real short-term advantage of laparoscopy according to technical difficulty are still lacking. The aim of the present study is to evaluate the differential benefit of laparoscopic over open technique according to the technical difficulty of the procedures and to investigate if efforts associated with laparoscopic approach are always justified.

Methods

Nine hundred and thirty-six MILS resections performed between 2005 and 2018 were stratified according to technical complexity (low, intermediate and high difficulty) and to approach (MILS or open) and matched in a 1:1 ratio using propensity scores to obtain three pairs of groups (Pair 1: Low-MILS and Low-Open, including 274 cases respectively; Pair 2: Int-MILS and Int-Open, including 237 patients respectively; Pair 3: High-MILS and High-Open, including 226 patients respectively).

Results

MILS approach resulted in a statistically significant lower blood loss, reduced morbidity, reduced and shorter time for functional recover and length of stay within all pairs. The evaluation of the differential benefit showed a greater advantage of laparoscopic approach in high degree procedures compared with intermediate and low degree, both in terms of blood loss (-250 and -200 mL respectively) and morbidity rate (-5.7% and -4.1% respectively).

Conclusions

The favorable biological scenario associated with laparoscopic approach allows to obtain significant benefits in the setting of technically complex procedures. The commitment towards MILS approach should be therefore stronger in this setting, where the advantage of laparoscopy seems to be enhanced.

Challenge and future of liver and pancreatic robotic surgery. Analysis of 64 cases in a specialized unit

INTRODUCTION

Robotic surgery has proven effective in certain surgical procedures. However, in liver and pancreatic surgery (HBP) its use is still rare. The initial experience in HBP robotic surgery of a specialized unit of a tertiary hospital is presented.

METHOD

The results of patients undergoing robotic HBP surgery between April 2018 and October 2020 have been prospectively studied. The data analyzed correspond to demographic data, surgical techniques performed, associated morbidity and mortality.

RESULTS

64 patients were operated, corresponding to 35 hepatectomies (major [6.7%], anatomic [52.9%], limited [34.4%], cystectomies [3%] and marsupialization [3%]), 29 pancreatectomies (distal [48.2%], central [6.9%], cephalic [13.8%], enucleations [24.1%], ampullectomies [3.5%] and duodenal resections [3.5%]). In liver surgery the mean operative time was 204.4 min (100-265 min), the median postoperative complications according to the Clavien-Dindo scale was one (1-4), the mean blood losses 166.7 mL (100-300 mL), there was no conversion and the mean postoperative stay was four days (2-14 days). In pancreatic surgery, the mean operative time was 243.8 min (125-460 min), the median of postoperative complications was two (1-4), blood loss of 202.3 mL (100-500 mL) associated to a conversion rate 17.8% and an average stay of seven days (3-23 days).

CONCLUSIONS

Robotic HBP surgery is safe and feasible. It is suggested that its use facilitates parenchymal sparing surgery, access to posterior liver segments and anastomosis in pancreatic reconstruction compared to laparoscopic surgery.

Role of Indocyanine Green Fluorescence Imaging in Minimally Invasive Resection of Colorectal Liver Metastases

Indocyanine green (ICG) fluorescence imaging is an easy and reproducible method to detect hepatic lesions, both primary and metastatic. This review reports the potential benefits of this technique as a tactile mimicking visual tool and a navigator guide in minimally invasive liver resection of colorectal liver metastases (CRLM). PubMed and MEDLINE databases were searched for studies reporting the use of intravenous injection of ICG before minimally invasive surgery for CLRM. The search was performed for publications reported from the first study in 2014 to April 2021. The final review included 13 articles: 6 prospective cohort studies, 1 retrospective cohort study, 3 case series, 1 case report, 1 case-matched study, and 1 clinical trial registry. The administered dose ranged between 0.3 and 0.5 mg/kg, while timing ranged between 1 and 14 days before surgery. CRLM detection rate ranged between 30.3% and 100% with preoperative imaging (abdominal computed tomography/magnetic resonance imaging), between 93.3 and 100% with laparoscopic ultrasound, between 57.6% and 100% with ICG fluorescence, and was 100% with combined modalities (ICG and laparoscopic ultrasound) with weighted averages of 77.42%, 95.97%, 79.03%, and 100%, respectively. ICG fusion imaging also allowed to detect occult small-sized lesions, not diagnosed preoperatively. In addition, ICG is effective in real-time assessment of surgical margins by evaluating the integrity of the fluorescent rim around the CRLM.

Minimally invasive surgical treatment of intrahepatic cholangiocarcinoma: A systematic review

BACKGROUND

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary liver cancer and is characterized by an aggressive behavior and a dismal prognosis. Radical surgical resection represents the only potentially curative treatment. Despite the increasing acceptance of laparoscopic liver resection for surgical treatment of malignant liver diseases, its use for ICC is not commonly performed. In fact, to achieve surgical free margins a major resection and/or vascular and/or biliary reconstructions is often needed, as well as an associated lymph node dissection.

AIM

To review and summarize the current evidences on the minimally invasive resection of ICC.

METHODS

A systematic review of the literature based on the criteria predetermined by the investigators was performed from the 1^st of January 2009 up to the 1^st of January 2021 in 4 databases (PubMed, Scopus, Google Scholar, and Cochrane databases). All retrospective and prospective studies reporting on the comparative outcomes of open vs minimally invasive treatment of ICC were included. An evaluation of manuscripts quality was achieved using Methodological Index for Non-Randomized Studies criteria and Newcastle-Ottawa Scale.

RESULTS

After a systematic search 9 studies fulfilled the inclusion criteria. Among the all 3012 included patients, 2450 were operated by an open approach and 562 by a minimally invasive (laparoscopic) approach. Baseline characteristics, tumor characteristics, surgical outcomes and oncological outcomes were collected and analyzed, highlighting values with a statistical significant difference between patients treated with open or laparoscopic approach. Shorter hospital stay and lower intraoperative blood losses were reported by some Authors in minimally invasive surgery, on the contrary, in the open group there was a higher number of lymphadenectomies and a higher percentage of major hepatectomies.

CONCLUSION

Minimally invasive resection of ICC has some short-term benefits and it is safe and feasible only in selected centers with a high experience in laparoscopic approach for liver surgery. Minimally invasive surgery, actually, was considered mainly in patients with a tumor with a diameter < 5 cm, without invasion of main biliary duct or main vessel and no vascular or biliary reconstructions were planned. Further studies are needed to elucidate its impact on long term oncologic outcomes.

Robotic infrahepatic vena cava clamping and Pringle manoeuvre for major hepatectomy: A safe and bloodless procedure - First technical report

Mini-invasive approaches in hepatic surgery are associated with a significant decrease in the incidence of post-operative morbidity and liver failure. Intraoperative blood loss represents the major intraoperative accident during hepatectomy. Infrahepatic inferior vena cava clamping is an emerging technical trick which guarantees a lower intraoperative blood loss and transfusion rates during liver surgery. Herein, we present the first report of infrahepatic caval clamping during robotic hepatectomy at our centre, highlighting some technical tips and tricks.

Open versus laparoscopic liver resection of colorectal metastases: a meta-analysis of matched patient populations

In recent years, the management of colorectal liver metastases (CRLM) has evolved significantly. Laparoscopic liver resection is increasingly being performed, despite a lack of major randomized controlled trial evidence or widespread international consensus. The objective of this review was to compare the short- and long-term outcomes following open and laparoscopic CRLM resection. A systematic review of comparative matched population studies was performed. Evaluated endpoints included surgical outcomes and survival outcomes. Twelve studies were included in this review, reporting on 3095 patients. R0 (negative margins) rates were higher in the laparoscopic CRLM group (89.3% versus 86.9%). In addition, laparoscopic resection was associated with less blood loss (486 mls versus 648 mls, p ≤ 0.0001*) and reduced blood transfusion rates (6.7% vs. 12.2%, OR 2.13, 95% CI 1.08-4.19, p = 0.03*). Major complication rates were higher in the open CRLM group (12.5% vs. 8.1%, OR 1.74, 95% CI 1.30-2.33, p = 0.03*), as was overall hospital length of stay (median 7 versus 5.5 days, p = 0.001*). Perioperative mortality was similar between both groups, and there was no significance in 5-year overall survival for open or laparoscopic CRLM resection groups (58% and 61% respectively). Laparoscopic CRLM resection is associated with less blood loss, lower transfusion rates, major complications, and overall hospital length of stay with comparable oncological outcome.

Team Strategy Optimization in Combined Resections for Synchronous Colorectal Liver Metastases. A Comparative Study with Bootstrapping Analysis

BACKGROUND

The aim of the study was to evaluate perioperative outcomes and to evaluate factors influencing rative morbidity and adoption of minimally invasive technique in 1-team (1-T) versus two teams (2-T) management of synchronous colorectal liver metastases.

METHODS

Within four referral centers, a group of 234 patients treated in 1-T centers was identified and compared with a group of 253 patients treated in 2-T. A nonparametric bootstrap process was applied to the original cohorts of 1-T group and 2-T group as a resampling method to obtain bootstrapped cohorts (155 patients per group).

RESULTS

33.5% of patients in 1-T boot group and 38.1% in the 2-T boot group were operated by laparoscopic approach. Multivariate analysis revealed that approach to primary tumor (laparoscopic or open) and intraoperative blood loss were independent prognostic factors for morbidity. Team approach did not show any significant correlation with incidence of postoperative complications nor with choice for laparoscopic approach.

CONCLUSION

The optimization of team strategy for patients with SCRLM is not solely based on the adoption of a 1-T or 2-T approach, but should instead be based on the implementation of a standard protocol for management of these patients.

Laparoscopic liver resection for colorectal liver metastases - short- and long-term outcomes: A systematic review

BACKGROUND

For well-selected patients and procedures, laparoscopic liver resection (LLR) has become the gold standard for the treatment of colorectal liver metastases (CRLM) when performed in specialized centers. However, little is currently known concerning patient-related and peri-operative factors that could play a role in survival outcomes associated with LLR for CRLM.

AIM

To provide an extensive summary of reported outcomes and prognostic factors associated with LLR for CRLM.

METHODS

A systematic search was performed in PubMed, EMBASE, Web of Science and the Cochrane Library using the keywords "colorectal liver metastases", "laparoscopy", "liver resection", "prognostic factors", "outcomes" and "survival". Only publications written in English and published until December 2019 were included. Furthermore, abstracts of which no accompanying full text was published, reviews, case reports, letters, protocols, comments, surveys and animal studies were excluded. All search results were saved to Endnote Online and imported in Rayyan for systematic selection. Data of interest were extracted from the included publications and tabulated for qualitative analysis.

RESULTS

Out of 1064 articles retrieved by means of a systematic and grey literature search, 77 were included for qualitative analysis. Seventy-two research papers provided data concerning outcomes of LLR for CRLM. Fourteen papers were eligible for extraction of data concerning prognostic factors affecting survival outcomes. Qualitative analysis of the collected data showed that LLR for CRLM is safe, feasible and provides oncological efficiency. Multiple research groups have reported on the short-term advantages of LLR compared to open procedures. The obtained results accounted for minor LLR, as well as major LLR, simultaneous laparoscopic colorectal and liver resection, LLR of posterosuperior segments, two-stage hepatectomy and repeat LLR for CRLM. Few research groups so far have studied prognostic factors affecting long-term outcomes of LLR for CRLM.

CONCLUSION

In experienced hands, LLR for CRLM provides good short- and long-term outcomes, independent of the complexity of the procedure.

Comparing practice and outcome of laparoscopic liver resection between high-volume expert centres and nationwide low-to-medium volume centres

BACKGROUND

Based on excellent outcomes from high-volume centres, laparoscopic liver resection is increasingly being adopted into nationwide practice which typically includes low-medium volume centres. It is unknown how the use and outcome of laparoscopic liver resection compare between high-volume centres and low-medium volume centres. This study aimed to compare use and outcome of laparoscopic liver resection in three leading European high-volume centres and nationwide practice in the Netherlands.

METHOD

An international, retrospective multicentre cohort study including data from three European high-volume centres (Oslo, Southampton and Milan) and all 20 centres in the Netherlands performing laparoscopic liver resection (low-medium volume practice) from January 2011 to December 2016. A high-volume centre is defined as a centre performing >50 laparoscopic liver resections per year. Patients were retrospectively stratified into low, moderate- and high-risk Southampton difficulty score groups.

RESULTS

A total of 2425 patients were included (1540 high-volume; 885 low-medium volume). The median annual proportion of laparoscopic liver resection was 42.9 per cent in high-volume centres and 7.2 per cent in low-medium volume centres. Patients in the high-volume centres had a lower conversion rate (7.4 versus 13.1 per cent; P < 0.001) with less intraoperative incidents (9.3 versus 14.6 per cent; P = 0.002) as compared to low-medium volume centres. Whereas postoperative morbidity and mortality rates were similar in the two groups, a lower reintervention rate (5.1 versus 7.2 per cent; P = 0.034) and a shorter postoperative hospital stay (3 versus 5 days; P < 0.001) were observed in the high-volume centres as compared to the low-medium volume centres. In each Southampton difficulty score group, the conversion rate was lower and hospital stay shorter in high-volume centres. The rate of intraoperative incidents did not differ in the low-risk group, whilst in the moderate-risk and high-risk groups this rate was lower in high-volume centres (absolute difference 6.7 and 14.2 per cent; all P < 0.004).

CONCLUSION

High-volume expert centres had a sixfold higher use of laparoscopic liver resection, less conversions, and shorter hospital stay, as compared to a nationwide low-medium volume practice. Stratification into Southampton difficulty score risk groups identified some differences but largely outcomes appeared better for high-volume centres in each risk group.

Laparoscopic Surgery for Intrahepatic Cholangiocarcinoma: A Focus on Oncological Outcomes

Background: The aim of the present study was to analyze the long-term outcomes of laparoscopic and open surgery for intrahepatic cholangiocarcinoma (iCCA) in a series, collected in a tertiary referral center with a high annual volume of laparoscopic activity. Methods: Between January 2004 and June 2020, 446 liver resections (LR) were performed for iCCA: of these, 179 were performed by laparoscopic surgery (LS) and 267 with the open approach. The two groups were matched through a 1:1 propensity score using covariates representative of patient and disease characteristics. The study and control groups were compared, with specific attention given to oncological outcomes (rate of R0, depth of resection margins, overall and disease-free survival, rate, and site of recurrence). Results: The number of retrieved nodes, rate, and depth of negative resection margins were comparable between the two groups. The interval time between surgery and subsequent adjuvant treatments was significantly shorter in LS patients. No differences were shown even in the comparison between the LS and the open group in terms of median disease-free and overall survival. Moreover, the disease recurrence rate was comparable between the LS and the open groups (45.2% versus 56.7%), and the recurrence pattern was similar. Conclusions: The minimally invasive approach for iCCA was once again confirmed to be associated with advantages in terms of intraoperative and short-term outcomes, but was also proven to be oncologically non-inferior to the open counterpart. In the present study, overall and disease-free survival were found to be similar between the two approaches.

Minimally invasive robotic-assisted combined colorectal and liver excision surgery: feasibility, safety and surgical technique in a pilot series

Different strategies may be adopted in patients with synchronous colorectal liver metastases (LM). The role of laparoscopy has been investigated to define the benefits of minimally invasive surgery in a single-stage operation. In our study, we report our experience of 28 Minimally Invasive Robotic-Assisted combined Colorectal and Liver Excision Surgery (MIRACLES). From October 2012 to December 2019, 135 Robotic liver resections and 218 Robotic Colorectal resections were performed in our center. Twenty-eight patients underwent MIRACLES resection with 37 nodules removed. Fifty-two lesions in 28 patients were resected in minimally invasive robot-assisted surgery. Eighteen lesions were located in postero-superior liver segments (eight in segment VII, two in segment VIII, eight in segment IVa). Nine right colectomies, seven left colectomies, ten anterior rectal resections, one Hartmann and one MILES procedures were performed. The median surgical time of MIRACLES procedures was 332 min. Two conversions to open approach were necessary. Four major complications (> III) were observed. No postoperative mortality was recorded. The median hospital stay was 8 days. The median overall survival was 27.5 months. The MIRACLES approach is feasible and safe for colorectal resection and hepatic nodules located in all segments, with a low rate of postoperative complications. Surgical technique is demanding and should be reserved, presently, to tertiary centers.

Intrahepatic cholangiocarcinoma as the new field of implementation of laparoscopic liver resection programs. A comparative propensity score-based analysis of open and laparoscopic liver resections

BACKGROUND

The aim of the present study is to analyze the outcomes of laparoscopic and open liver resections for (Intrahepatic CholangioCarcinoma) ICC in the modern era of laparoscopic liver surgery.

METHODS

Patients undergoing laparoscopic and open liver resections for ICC in two European referral centers were included. Finally, 104 patients from the open group and 104 patients from the laparoscopic group were compared after propensity scores matching according to seven covariates representative of patients and disease characteristics. Indications to surgery and short- and long-term outcomes were compared.

RESULTS

Operative time, number of retrieved nodes, rate, and depth of negative resection margins were comparable between the two groups. Blood loss was lower in the MILS (150 ± 100 mL, mean ± SD) compared with the Open group (350 ± 250 mL, p = 0.030). Postoperative complications occurred in 14.4% of patients in the MILS and in the 24% of patients in the Open group (p = 0.02). There were no significant differences in long-term outcomes between groups.

CONCLUSIONS

Our results confirm feasibility, safety, and oncological efficiency of the laparoscopic approach in the management of ICC. However, this surgery is often complex and should be only considered in centers with large experience in laparoscopic liver surgery.

Challenge and future of liver and pancreatic robotic surgery. Analysis of 64 cases in a specialized unit

INTRODUCTION

Robotic surgery has proven effective in certain surgical procedures. However, in liver and pancreatic surgery (HBP) its use is still rare. The initial experience in HBP robotic surgery of a specialized unit of a tertiary hospital is presented.

METHOD

The results of patients undergoing robotic HBP surgery between April 2018 and October 2020 have been prospectively studied. The data analyzed correspond to demographic data, surgical techniques performed, associated morbidity and mortality.

RESULTS

64 patients were operated, corresponding to 35 hepatectomies (major [6.7%], anatomic [52.9%], limited [34.4%], cystectomies [3%] and marsupialization [3%]), 29 pancreatectomies (distal [48.2%], central [6.9%], cephalic [13.8%], enucleations [24.1%], ampullectomies [3.5%] and duodenal resections [3.5%]). In liver surgery the mean operative time was 204.4 minutes (100-265 min), the median postoperative complications according to the Clavien-Dindo scale was one (1-4), the mean blood losses 166.7 mL (100-300 mL), there was no conversion and the mean postoperative stay was four days (2-14 days). In pancreatic surgery, the mean operative time was 243.8 minutes (125-460 min), the median of postoperative complications was two (1-4), blood loss of 202.3 mL (100-500 mL) associated to a conversion rate 17.8% and an average stay of seven days (3-23 days).

CONCLUSIONS

Robotic HBP surgery is safe and feasible. It is suggested that its use facilitates parenchymal sparing surgery, access to posterior liver segments and anastomosis in pancreatic reconstruction compared to laparoscopic surgery.

Evolution of Surgical Treatment of Colorectal Liver Metastases in the Real World: Single Center Experience in 1212 Cases

BACKGROUND

In recent years, the treatment of colorectal liver metastases (CRLM) has undergone significant evolution thanks to technical improvements as well as oncological advances, which have been the subject of targeted studies aimed at understanding the details of this heterogeneous disease. The purpose of this study is to put together pieces of this complex scenario by providing an overview of the evolution that has occurred in the context of a single center within a multidisciplinary management approach.

METHODS

Between 2005 and 2020, 1212 resections for CRLM were performed at the Hepatobiliary Surgery Division of San Raffaele Hospital, Milan. The series was divided into three historical periods, which were compared in terms of disease characteristics and short- and long-term outcomes: Period 1, 2005-2009 (293 cases); Period 2, 2010-2014 (353 cases); Period 3, 2015-2020 (566 cases). The trends for surgical technical complexity, oncological burden of the disease, use of the laparoscopic approach and use of techniques for hepatic hypertrophy were analyzed year by year. Uni- and multivariate analyses were performed to identify factors associated with inclusion to a laparoscopic approach and with long-term prognosis.

RESULTS

The number of resections performed over the years progressively increased, with an increase in the number of cases with a high Clinical Risk Score and a high profile of technical complexity. The proportion of cases performed laparoscopically increased, but less rapidly compared to other malignant tumors. The risk of postoperative morbidity and mortality was similar in the three analyzed periods. Long-term survival, stratified by Clinical Risk Score, improved in Period 3, while overall survival remained unchanged.

CONCLUSION

The cultural background, the maturation of technical expertise and the consolidation of the multidisciplinary team have resulted in safe expansion of the possibility to offer a curative opportunity to patients, while continuously implementing into clinical practice evidence provided by the literature.

Improving vision for surgeons during laparoscopy: the Enhanced Laparoscopic Vision System (ELViS)

BACKGROUND

For many abdominal surgical interventions, laparotomy has gradually been replaced by laparoscopy, with numerous benefits for the patient in terms of post-operative recovery. However, during laparoscopy, the endoscope only provides a single viewpoint to the surgeon, leaving numerous blind spots and opening the way to peri-operative adverse events. Alternative camera systems have been proposed, but many lack the requisite resolution/robustness for use during surgery or cannot provide real-time images. Here, we present the added value of the Enhanced Laparoscopic Vision System (ELViS) which overcomes these limitations and provides a broad view of the surgical field in addition to the usual high-resolution endoscope.

METHODS

Experienced laparoscopy surgeons performed several typical procedure steps on a live pig model. The time-to-completion for surgical exercises performed by conventional endoscopy and ELViS-assisted surgery was measured. A debriefing interview following each operating session was conducted by an ergonomist, and a System Usability Scale (SUS) score was determined.

RESULTS

Proof of concept of ELVIS was achieved in an animal model with seven expert surgeons without peroperative adverse events related to the surgical device. No differences were found in time-to-completion. Mean SUS score was 74.7, classifying the usability of the ELViS as "good". During the debriefing interview, surgeons highlighted several situations where the ELViS provided a real advantage (such as during instrument insertion, exploration of the abdominal cavity or for orientation during close work) and also suggested avenues for improvement of the system.

CONCLUSIONS

This first test of the ELViS prototype on a live animal model demonstrated its usability and provided promising and useful feedback for further development.

Subcuticular sutures reduce surgical site infection after repeat liver resection: a matched cohort analysis

Liver cancer frequently requires repeated liver resections due to the high recurrence rate. The aim of this study was to clarify whether subcuticular sutures reduce wound complication rates following repeat incisions. Data from 382 repeated liver resections in 1,245 consecutive patients were assessed. Patients were divided into a Subcuticular sutures group and a Skin staples group on the basis of the wound-closure method. To avoid bias in analysing wound complications, data were matched to adjust for patient background and operation variables. After matching, 82 matched, paired patients with subcuticular sutures or skin staples were compared. Total wound complication rate was significantly lower with subcuticular sutures than with skin staples (8.5% vs. 20.7%, p = 0.027). Incisional surgical site infection was also lower with subcuticular sutures than with skin staples (6.1% vs. 17.1, p = 0.028). Univariate analysis revealed 4 factors associated with wound complications: body mass index; serum albumin concentration; wound length; and closure with skin staples. Multivariate analysis revealed closure with skin staples (odds ratio, 2.91; 95% confidence interval, 1.07-7.94; p = 0.037) as the only independent factor negatively associated with wound complications. Subcuticular sutures appear to reduce wound complications compared to skin staples following repeat incision for liver resection.

Minimal-Invasive Versus Open Hepatectomy for Colorectal Liver Metastases: Bicentric Analysis of Postoperative Outcomes and Long-Term Survival Using Propensity Score Matching Analysis

Minimal-invasive hepatectomy (MIH) has been increasingly performed for benign and malignant liver lesions with most promising short-term results. However, the oncological role of MIH in the treatment of patients with colorectal liver metastases (CRLM) needs further investigation. Clinicopathological data of patients who underwent liver resection for CRLM between 2012 and 2017 at the Department of Surgery, Charité-Universitätsmedizin Berlin, and the Inselspital Bern were assessed. Postoperative outcomes und long-term survivals of patients following MIH were compared with those after conventional open hepatectomy (OH) after 1:1 propensity score matching. During the study period, 229 and 91 patients underwent liver resection for CRLM at the Charité Berlin and the Inselspital Bern, respectively. Patients who underwent MIH in one of the two centers (n = 69) were compared with a matched cohort of patients who underwent OH. MIH was associated with lower complication rates (23% vs. 44%, p = 0.011), shorter length of intensive care unit stay (ICU, 1 vs. 2 days, p = 0.043), shorter length of hospital stay (7 vs. 11 days, p < 0.0001), and a reduced need for intraoperative transfusions (12% vs. 25%, p = 0.047) compared to OH. R0 status was achieved in 93% and 75% of patients after MIH and OH, respectively (p = 0.005). After a median follow-up of 31 months, MIH resulted in similar five-year overall survival (OS) rate (56% vs. 48%, p = 0.116) in comparison to OH. MIH for CRLM is associated with lower postoperative morbidity, shorter length of ICU and hospital stay, reduced need for transfusions, and comparable oncologic outcomes compared to the established OH. Our findings suggest that MIH should be considered as the preferred method for the treatment of curatively resectable CRLM.

Clinical practice guidelines for the management of liver metastases from extrahepatic primary cancers 2021

BACKGROUND

Hepatectomy is standard treatment for colorectal liver metastases; however, it is unclear whether liver metastases from other primary cancers should be resected or not. The Japanese Society of Hepato-Biliary-Pancreatic Surgery therefore created clinical practice guidelines for the management of metastatic liver tumors.

METHODS

Eight primary diseases were selected based on the number of hepatectomies performed for each malignancy per year. Clinical questions were structured in the population, intervention, comparison, and outcomes (PICO) format. Systematic reviews were performed, and the strength of recommendations and the level of quality of evidence for each clinical question were discussed and determined. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations.

RESULTS

The eight primary sites were grouped into five categories based on suggested indications for hepatectomy and consensus of the guidelines committee. Fourteen clinical questions were devised, covering five topics: (1) diagnosis, (2) operative treatment, (3) ablation therapy, (4) the eight primary diseases, and (5) systemic therapies. The grade of recommendation was strong for one clinical question and weak for the other 13 clinical questions. The quality of the evidence was moderate for two questions, low for 10, and very low for two. A flowchart was made to summarize the outcomes of the guidelines for the indications of hepatectomy and systemic therapy.

CONCLUSIONS

These guidelines were developed to provide useful information based on evidence in the published literature for the clinical management of liver metastases, and they could be helpful for conducting future clinical trials to provide higher-quality evidence.

Is laparoscopic liver resection safe for intrahepatic cholangiocarcinoma? A meta-analysis

BACKGROUND

The use of laparoscopic liver resection for curative surgery of intrahepatic cholangiocarcinoma (ICC) is not well established. Herein, we perform a meta-analysis to compare the differences between laparoscopic liver resection (LLR) and open liver resection (OLR) for ICC.

METHODS

Multiple electronic databases were searched and 8 relevant studies containing 552 patients treated by LLR and 2320 treated by OLR were identified. The fixed effects and a random-effects model were used to perform a meta-analysis.

RESULTS

Compared with OLR, LLR for ICC was associated with less blood transfusion (7.14% versus 17.11%; OR: 0.32; 95% CI 0.15 to 0.71; P < 0.05), higher R0 resection (85.63% versus 74.69%; OR: 1.48; 95% CI 1.13 to 1.95; P < 0.05), shorter length of stay (LOS) (SMD: -0.40; 95% CI -0.80 to 0.00; P = 0.05), less overall morbidities (20% versus 32.69%; OR: 0.50; 95% CI 0.33 to 0.78; P < 0.05), and less death due to tumor recurrence (22.39% versus 35.48%; OR: 0.50; 95% CI 0.29 to 0.86; P <0.05); but LLR was associated with smaller ICC, fewer major hepatectomies, less lymph node (LN) dissection rate, and inferior 5-year overall survival (OS) (P < 0.05). Duration of operation, blood loss, average LN retrieved, LN metastasis, major morbidities, mortality, tumor recurrence, 3-year OS and disease free survival (DFS), and 5-year DFS were comparable (P >0.05).

CONCLUSION

LLR for ICC is in the initial phase of exploration. More evidence is necessary to validate LLR for ICC.

Survival Advantage of Laparoscopic Versus Open Resection For Colorectal Liver Metastases: A Meta-analysis of Individual Patient Data From Randomized Trials and Propensity-score Matched Studies

OBJECTIVE

To perform an individual participant data meta-analysis using randomized trials and propensity-score matched (PSM) studies which compared laparoscopic versus open hepatectomy for patients with colorectal liver metastases (CLM).

BACKGROUND

Randomized trials and PSM studies constitute the highest level of evidence in addressing the long-term oncologic efficacy of laparoscopic versus open resection for CLM. However, individual studies are limited by the reporting of overall survival in ways not amenable to traditional methods of meta-analysis, and violation of the proportional hazards assumption.

METHODS

Survival information of individual patients was reconstructed from the published Kaplan-Meier curves with the aid of a computer vision program. Frequentist and Bayesian survival models (taking into account random-effects and nonproportional hazards) were fitted to compare overall survival of patients who underwent laparoscopic versus open surgery. To handle long plateaus in the tails of survival curves, we also exploited "cure models" to estimate the fraction of patients effectively "cured" of disease.

RESULTS

Individual patient data from 2 randomized trials and 13 PSM studies involving 3148 participants were reconstructed. Laparoscopic resection was associated with a lower hazard rate of death (stratified hazard ratio = 0.853, 95% confidence interval: 0.754-0.965, P = 0.0114), and there was evidence of time-varying effects (P = 0.0324) in which the magnitude of hazard ratios increased over time. The fractions of long-term cancer survivors were estimated to be 47.4% and 18.0% in the laparoscopy and open surgery groups, respectively. At 10-year follow-up, the restricted mean survival time was 8.6 months (or 12.1%) longer in the laparoscopy arm (P < 0.0001). In a subgroup analysis, elderly patients (≥65 years old) treated with laparoscopy experienced longer 3-year average life expectancy (+6.2%, P = 0.018), and those who live past the 5-year milestone (46.1%) seem to be cured of disease.

CONCLUSIONS

This patient-level meta-analysis of high-quality studies demonstrated an unexpected survival benefit in favor of laparoscopic over open resection for CLM in the long-term. From a conservative viewpoint, these results can be interpreted to indicate that laparoscopy is at least not inferior to the standard open approach.

Timing of Perioperative Chemotherapy Does Not Influence Long-Term Outcome of Patients Undergoing Combined Laparoscopic Colorectal and Liver Resection in Selected Upfront Resectable Synchronous Liver Metastases

BACKGROUND

The aim of this study was to compare patients undergoing combined colorectal and hepatic surgery with and without neoadjuvant chemotherapy to clarify the prognostic advantage of preoperative oncological treatment in a case-matched analysis using propensity scores and to identify factors predictive of good prognosis in a selected population of Synchronous ColoRectal Liver Metastases (SCRLM).

METHODS

A total of 73 patients who underwent upfront elective combined surgery without preoperative CT for SCRLM in two European tertiary referral centers were selected and constituted the study group (NoNACT group). The NoNACT group was matched (ratio 1:1) with patients who were operated after chemotherapy with neoadjuvant intent (NACT group, the control group). The matching was achieved based on six covariates representative of patients and disease characteristics.

RESULTS

While the characteristics of both colorectal and hepatic procedures were similar, the NoNACT group, as compared to the NACT group, had lower blood loss (200 mL vs. 550 mL). Postoperative stay (9 vs. 12 days) and morbidity rate (24.7% vs. 32.9%) were reduced in the NoNACT compared with the NACT group. Mid- and long-term outcomes were comparable. At multivariable analysis, predictors of long-term outcome were: right colonic neoplasms, RAS mutational status, CRS score ≥3 and the absence of perioperative chemotherapy.

CONCLUSION

Preoperative neoadjuvant chemotherapy in patients with colorectal cancer and synchronous resectable liver metastases does not influence the risk of recurrence in patients with favorable tumor biology, while it was associated with increased intraoperative blood loss and morbidity. There is no strong evidence to recommend upfront chemotherapy in the absence of negative prognostic factors.

Diagnostic performance of magnetic resonance imaging for colorectal liver metastasis: A systematic review and meta-analysis

The prognosis of colorectal cancer (CRC) is largely dependent on the early detection of hepatic metastases. With the advantages of nonradioactivity and the availability of multiple scanning sequences, the efficacy of magnetic resonance imaging (MRI) in the detection of colorectal liver metastases (CRLM) is not yet clear. We performed this meta-analysis to address this issue. PubMed, Embase, and the Cochrane Library were searched for studies reporting diagnostic performance of MRI for CRLM. Descriptive and quantitative data were extracted. The study quality was evaluated for the identified studies and a random effects model was used to determine the integrated diagnosis estimation. Meta-regression and subgroup analyses were implemented to investigate the potential contributors to heterogeneity. As a result, seventeen studies were included for analysis (from the year 1996 to 2018), comprising 1121 patients with a total of 3279 liver lesions. The pooled sensitivity, specificity, and diagnostic odds ratio were 0.90 (95% confidence intervals (CI): 0.81-0.95), 0.88 (0.80-0.92), and 62.19 (23.71-163.13), respectively. The overall weighted area under the curve was 0.94 (0.92-0.96). Using two or more imaging planes and a quantitative/semiquantitative interpretation method showed higher diagnostic performance, although only the latter demonstrated statistical significance (P < 0.05). Advanced scanning sequences with DWI and liver-specific contrast media tended to increase the sensitivity for CRLM detection. We therefore concluded that contemporary MRI has high sensitivity and specificity for screening CRLM, especially for those with advanced scanning sequences. Using two or more imaging planes and adopting a quantitative/semiquantitative imaging interpretation may further improve diagnosis. However, the MRI results should be interpreted with caution because of substantial heterogeneity among studies.

Minimally invasive cancer surgery is associated with a lower risk of venous thromboembolic events

BACKGROUND

Venous thromboembolism (VTE) is a significant source of postoperative morbidity and mortality in patients undergoing common oncologic procedures. We sought to estimate the effect of surgical approach on the risk of developing a VTE.

METHODS

IBM Watson Health Marketscan Database was used to conduct this retrospective study. In total, 12 938 patients who underwent either a radical prostatectomy, partial colectomy, or hysterectomy via a minimally invasive or open approach. We used a propensity-weighted logistic regression analysis to assess the independent effect of surgical approach on VTE. The primary outcome of interest was the 90-day rate of VTE after surgery.

RESULTS

Patients undergoing minimally invasive surgery across all three surgical procedures were noted to have a lower odds of developing a VTE: (radical prostatectomy, odds ratio [OR]: 0.667, 95% confidence interval [CI]: 0.500-0.891; P = .006 |partial colectomy: OR, 0.620, 95% CI: 0.477-0.805; P < .001| hysterectomy: OR, 0.549 95% CI: 0.353-0.854; P = .008).

CONCLUSION

We found that a minimally invasive approach was associated with significantly lower odds of VTE compared with undergoing the same open procedure. This study highlights how surgical approach may be an independent risk factor for development of VTE and may elucidate potential risk mitigation strategy.

Major hepatectomy for intrahepatic cholangiocarcinoma or colorectal liver metastases. Are we talking about the same story?

INTRODUCTION

Major hepatectomy (MH) is often needed in the curative management of intrahepatic cholangiocarcinoma (IHCC) and colorectal liver metastases (CRLM). While similar outcomes could be expected after MH for IHCC and CRLM, outcomes seem worse after MH for IHCC. A better understanding of such differences might help improving perioperative outcomes but comprehensive analysis are lacking.

METHODS

All patients undergoing curative intent MH for IHCC or CRLM from 2003 to 2009 were included from two dedicated multi-institutional datasets. Preoperative management and short-term outcomes after MH were first compared. Independent predictors of postoperative mortality and morbidity were identified.

RESULTS

Among 827 patients, 333 and 494 patients underwent MH for IHCC and CRLM, respectively. Preoperative portal vein embolization was more frequently performed in the CRLM group (p < 0.001). MH in the IHCC group required more extended resection (p < 0.001). Postoperative mortality and severe morbidity rates were significantly higher in the IHCC group (7.2% vs. 1.2% and 29.7% vs. 11.1%, p < 0.001, respectively). Main causes for mortality were postoperative liver failure and deep surgical site infection. MH for IHCC was an independent risk factor for mortality (p < 0.001) and severe morbidity (p < 0.001). After propensity score matching (212 patients in each group), the aforementioned differences regarding outcomes remained statistically significant.

CONCLUSION

This study suggests that IHCC patients are inherently more at risk after MH as compared to CRLM patients. Considering that postoperative liver failure was the most frequent cause of death, preoperative planning might have been inadequate in the setting of IHCC while more complex/extended resections should be expected.

Safety and feasibility of laparoscopic liver resection for patients with large or multiple intrahepatic cholangiocarcinomas: A propensity score based case-matched analysis from a single institute

Only a few high-volume centers have reported the efficacy of laparoscopic liver resection (LLR) for patients with intrahepatic cholangiocarcinoma (ICC). The minimally invasive approach is still controversial for ICC, especially when dealing with large (≥5 cm) or multiple (≥2) ICCs.Patients with large and multiple ICCs who underwent LLR or open hepatectomy (OH) between January 2012 and June 2017 were included. Furthermore, 1:2 propensity score matching (PSM) was performed between the LLR group and the OH group. Short- and long-term outcomes were compared between the different techniques.After PSM, LLR resulted in significantly longer operation time (median 225 minutes vs 190 minutes, P = .006) and pringle maneuver time (median 50 minutes vs 32.5 minutes, P = .001). There was no statistically significant difference in postoperative hospital stay between the different approaches (median 6 days vs 7 days, P = .092). The grade III/IV complication rates were comparable between the groups (5.6% vs 11.1%, P = .868). In the PSM subset, there was no significant difference in terms of overall survival (P = .645) or disease-free survival (P = .827) between patients in the LLR group and in the OH group.The present study showed that patients who underwent LLR for large or multiple ICCs could obtain similar short- and long-term outcomes compared with those who underwent OH, and lymph node dissection (LND) was technically difficult but feasible during LLR.