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Thierry G, Beck F, Hardy PY, Kaba A, Blanjean A, Vandermeulen M, Honoré P, Joris J, Bonhomme V, Detry O. Impact of enhanced recovery program implementation on postoperative outcomes after liver surgery: a monocentric retrospective study. Surg Endosc 2024; 38:3253-3262. [PMID: 38653900 DOI: 10.1007/s00464-024-10796-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/10/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION It is still unclear whether enhanced recovery programs (ERPs) reduce postoperative morbidity after liver surgery. This study investigated the effect on liver surgery outcomes of labeling as a reference center for ERP. MATERIALS AND METHODS Perioperative data from 75 consecutive patients who underwent hepatectomy in our institution after implementation and labeling of our ERP were retrospectively compared to 75 patients managed before ERP. Length of hospital stay, postoperative complications, and adherence to protocol were examined. RESULTS Patient demographics, comorbidities, and intraoperative data were similar in the two groups. Our ERP resulted in shorter length of stay (3 days [1-6] vs. 4 days [2-7.5], p = 0.03) and fewer postoperative complications (24% vs. 45.3%, p = 0.0067). This reduction in postoperative morbidity can be attributed exclusively to a lower rate of minor complications (Clavien-dindo grade < IIIa), and in particular to a lower rate of postoperative ileus, after labeling. (5.3% vs. 25.3%, p = 0.0019). Other medical and surgical complications were not significantly reduced. Adherence to protocol improved after labeling (17 [16-18] vs. 14 [13-16] items, p < 0.001). CONCLUSIONS The application of a labeled enhanced recovery program for liver surgery was associated with a significant shortening of hospital stay and a halving of postoperative morbidity, mainly ileus.
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Affiliation(s)
- Gabriel Thierry
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium.
- Groupe Francophone de Réhabilitation Améliorée Après Chirurgie (GRACE ; Francophone Group for Enhanced Recovery After Surgery), Beaumont, France.
- Inflammation and Enhanced Rehabilitation Laboratory (Regional Anesthesia and Analgesia), GIGA-I3 Thematic Unit, GIGA-Research, Liege University, Liege, Belgium.
- CREDEC: Centre de Recherche et d'Enseignement du Département de Chirurgie GIGA Metabolism, University of Liege, Domaine du Sart Tilman, Liege, Belgium.
| | - Florian Beck
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
- Anesthesia and Perioperative Neuroscience Laboratory, GIG-Consciousness Thematic Unit, GIGA-Research, Liege University, Liege, Belgium
| | - Pierre-Yves Hardy
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
- Groupe Francophone de Réhabilitation Améliorée Après Chirurgie (GRACE ; Francophone Group for Enhanced Recovery After Surgery), Beaumont, France
- Inflammation and Enhanced Rehabilitation Laboratory (Regional Anesthesia and Analgesia), GIGA-I3 Thematic Unit, GIGA-Research, Liege University, Liege, Belgium
| | - Abdourahamane Kaba
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
- Inflammation and Enhanced Rehabilitation Laboratory (Regional Anesthesia and Analgesia), GIGA-I3 Thematic Unit, GIGA-Research, Liege University, Liege, Belgium
| | - Arielle Blanjean
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
- Groupe Francophone de Réhabilitation Améliorée Après Chirurgie (GRACE ; Francophone Group for Enhanced Recovery After Surgery), Beaumont, France
| | - Morgan Vandermeulen
- Department of Abdominal Surgery and Transplantation, Liege University Hospital, Liege, Belgium
- CREDEC: Centre de Recherche et d'Enseignement du Département de Chirurgie GIGA Metabolism, University of Liege, Domaine du Sart Tilman, Liege, Belgium
| | - Pierre Honoré
- Department of Abdominal Surgery and Transplantation, Liege University Hospital, Liege, Belgium
| | - Jean Joris
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
- Groupe Francophone de Réhabilitation Améliorée Après Chirurgie (GRACE ; Francophone Group for Enhanced Recovery After Surgery), Beaumont, France
| | - Vincent Bonhomme
- Department of Anesthesia and Intensive Care Medicine, Liege University Hospital, Liege, Belgium
- Anesthesia and Perioperative Neuroscience Laboratory, GIG-Consciousness Thematic Unit, GIGA-Research, Liege University, Liege, Belgium
| | - Olivier Detry
- Department of Abdominal Surgery and Transplantation, Liege University Hospital, Liege, Belgium
- CREDEC: Centre de Recherche et d'Enseignement du Département de Chirurgie GIGA Metabolism, University of Liege, Domaine du Sart Tilman, Liege, Belgium
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Fichtinger RS, Aldrighetti LA, Abu Hilal M, Troisi RI, Sutcliffe RP, Besselink MG, Aroori S, Menon KV, Edwin B, D'Hondt M, Lucidi V, Ulmer TF, Díaz-Nieto R, Soonawalla Z, White S, Sergeant G, Olij B, Ratti F, Kuemmerli C, Scuderi V, Berrevoet F, Vanlander A, Marudanayagam R, Tanis P, Dewulf MJ, Dejong CH, Eminton Z, Kimman ML, Brandts L, Neumann UP, Fretland ÅA, Pugh SA, van Breukelen GJ, Primrose JN, van Dam RM. Laparoscopic Versus Open Hemihepatectomy: The ORANGE II PLUS Multicenter Randomized Controlled Trial. J Clin Oncol 2024; 42:1799-1809. [PMID: 38640453 PMCID: PMC11107897 DOI: 10.1200/jco.23.01019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 11/13/2023] [Accepted: 01/17/2024] [Indexed: 04/21/2024] Open
Abstract
PURPOSE To compare outcomes after laparoscopic versus open major liver resection (hemihepatectomy) mainly for primary or metastatic cancer. The primary outcome measure was time to functional recovery. Secondary outcomes included morbidity, quality of life (QoL), and for those with cancer, resection margin status and time to adjuvant systemic therapy. PATIENTS AND METHODS This was a multicenter, randomized controlled, patient-blinded, superiority trial on adult patients undergoing hemihepatectomy. Patients were recruited from 16 hospitals in Europe between November 2013 and December 2018. RESULTS Of the 352 randomly assigned patients, 332 patients (94.3%) underwent surgery (laparoscopic, n = 166 and open, n = 166) and comprised the analysis population. The median time to functional recovery was 4 days (IQR, 3-5; range, 1-30) for laparoscopic hemihepatectomy versus 5 days (IQR, 4-6; range, 1-33) for open hemihepatectomy (difference, -17.5% [96% CI, -25.6 to -8.4]; P < .001). There was no difference in major complications (laparoscopic 24/166 [14.5%] v open 28/166 [16.9%]; odds ratio [OR], 0.84; P = .58). Regarding QoL, both global health status (difference, 3.2 points; P < .001) and body image (difference, 0.9 points; P < .001) scored significantly higher in the laparoscopic group. For the 281 (84.6%) patients with cancer, R0 resection margin status was similar (laparoscopic 106 [77.9%] v open 122 patients [84.1%], OR, 0.60; P = .14) with a shorter time to adjuvant systemic therapy in the laparoscopic group (46.5 days v 62.8 days, hazard ratio, 2.20; P = .009). CONCLUSION Among patients undergoing hemihepatectomy, the laparoscopic approach resulted in a shorter time to functional recovery compared with open surgery. In addition, it was associated with a better QoL, and in patients with cancer, a shorter time to adjuvant systemic therapy with no adverse impact on cancer outcomes observed.
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Affiliation(s)
- Robert S. Fichtinger
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | | | - Mohammed Abu Hilal
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, United Kingdom
- Department of Surgery, Poliambulanza Hospital, Brescia, Italy
| | - Roberto I. Troisi
- Division of HPB, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Transplantation Service, Federico II University, Naples, Italy
- Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital, Ghent, Belgium
| | - Robert P. Sutcliffe
- Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Somaiah Aroori
- Department of Surgery, Plymouth Hospitals NHS Trust, Plymouth, United Kingdom
| | - Krishna V. Menon
- Department of Surgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Bjørn Edwin
- Intervention Center and Department of Hepatic, Pancreatic and Biliary Surgery, Oslo University Hospital and Institute of Medicine, University of Oslo, Oslo, Norway
| | - Mathieu D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, AZ Groeninge, Kortrijk, Belgium
| | - Valerio Lucidi
- Department of Digestive Surgery, Unit of Hepatobiliary Surgery and Transplantation, Hôpitaux Universitaires de Bruxelles, Hôpital Erasme, Brussels, Belgium
| | - Tom F. Ulmer
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Rafael Díaz-Nieto
- Department of Hepato-Biliary Surgery, Aintree University Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Zahir Soonawalla
- Department of Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Steve White
- Department of Surgery, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Gregory Sergeant
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Jessa Hospital, Hasselt, Belgium
| | - Bram Olij
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- GROW—School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - Francesca Ratti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - Christoph Kuemmerli
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, United Kingdom
| | - Vincenzo Scuderi
- Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital, Ghent, Belgium
| | - Frederik Berrevoet
- Department of General, Hepatobiliary and Liver Transplantation Surgery, Ghent University Hospital, Ghent, Belgium
| | - Aude Vanlander
- Department of Surgery, Free University Hospital, AZ Jette Hospital, Brussels, Belgium
| | - Ravi Marudanayagam
- Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Pieter Tanis
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, the Netherlands
| | - Maxime J.L. Dewulf
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Cornelis H.C. Dejong
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Deceased
| | - Zina Eminton
- Southampton Clinical Trials Unit, University of Southampton, Southampton, United Kingdom
| | - Merel L. Kimman
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Lloyd Brandts
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Ulf P. Neumann
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Department of Surgery, University Hospital Essen, Essen, Germany
| | - Åsmund A. Fretland
- Intervention Center and Department of Hepatic, Pancreatic and Biliary Surgery, Oslo University Hospital and Institute of Medicine, University of Oslo, Oslo, Norway
| | - Siân A. Pugh
- Department of Oncology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Gerard J.P. van Breukelen
- Department of Methodology and Statistics, CAPHRI Care and Public Health Research Institute Maastricht University, Maastricht, the Netherlands
| | - John N. Primrose
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, United Kingdom
| | - Ronald M. van Dam
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- GROW—School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
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Drefs M, Schoenberg MB, Börner N, Koliogiannis D, Koch DT, Schirren MJ, Andrassy J, Bazhin AV, Werner J, Guba MO. Changes of long-term survival of resection and liver transplantation in hepatocellular carcinoma throughout the years: A meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107952. [PMID: 38237275 DOI: 10.1016/j.ejso.2024.107952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 12/21/2023] [Accepted: 01/03/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Hepatocellular Carcinoma (HCC) still is one of the most detrimental malignant diseases in the world. As two curative surgical therapies exist, the discussion whether to opt for liver resection (LR) or transplantation (LT) is ongoing, especially as novel techniques to improve outcome have emerged for both. The aim of the study was to investigate how the utilization and outcome of the respective modalities changed through time. METHODS We searched Medline and PubMed for relevant publications comparing LT and LR in HCC patients during the time period from 1990 to 2022, prior to March 31, 2023. A total of 63 studies involving 19,804 patients - of whom 8178 patients received a liver graft and 11,626 underwent partial hepatectomy - were included in this meta-analysis. RESULTS LT is associated with significantly better 5-year overall survival (OS) (64.83%) and recurrence-free survival (RFS) (70.20%) than LR (OS: 50.83%, OR: 1.79, p < 0.001; RFS: 34.46%, OR: 5.32, p < 0.001). However, these differences are not as evident in short-term intervals. Older cohorts showed comparable disparities between the outcome of the respective modalities, as did newer cohorts after 2005. This might be due to the similar improvement in survival rates that were observed for both, LT (15-23%) and LR (12-20%) during the last 30 years. CONCLUSION LT still outperforms LR in the therapy of HCC in terms of long-term survival rates. Yet, LR outcome has remarkably improved which is of major importance in reference to the well-known limitations that occur in LT.
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Affiliation(s)
- Moritz Drefs
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany.
| | - Markus B Schoenberg
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany; Faculty of Medicine, LMU Munich, Germany; Medical Centers Gollierplatz and Nymphenburg, Munich, Germany
| | - Nikolaus Börner
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany
| | - Dionysios Koliogiannis
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany
| | - Dominik T Koch
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany
| | - Malte J Schirren
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany
| | - Joachim Andrassy
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany
| | - Alexandr V Bazhin
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany; Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Jens Werner
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany; Faculty of Medicine, LMU Munich, Germany; Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Markus O Guba
- Department of General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Germany; Transplantation Center Munich, LMU University Hospital, LMU Munich, Germany
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Pan SB, Wu CL, Zhou DC, Xiong QR, Geng XP, Hou H. Total laparoscopic partial hepatectomy versus open partial hepatectomy for primary left-sided hepatolithiasis: study protocol for a randomized controlled trial. Trials 2024; 25:137. [PMID: 38383461 PMCID: PMC10882851 DOI: 10.1186/s13063-023-07476-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 06/26/2023] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND The advantages of laparoscopic left-sided hepatectomy (LLH) for treating hepatolithiasis in terms of the time to postoperative length of hospital stay (LOS), morbidity, long-term abdominal wall hernias, hospital costs, residual stone rate, and recurrence of calculus have not been confirmed by a randomized controlled trial. The aim of this trial is to compare the safety and effectiveness of LLH with open left-sided hepatectomy (OLH) for the treatment of hepatolithiasis. METHODS Patients with hepatolithiasis eligible for left-sided hepatectomy will be recruited. The experimental design will produce two randomized arms (laparoscopic and open hepatectomy) at a 1:1 ratio and a prospective registry. All patients will undergo surgery in the setting of an enhanced recovery after surgery (ERAS) programme. The prospective registry will be based on patients who cannot be randomized because of the explicit treatment preference of the patient or surgeon or because of ineligibility (not meeting the inclusion and exclusion criteria) for randomization in this trial. The primary outcome is the LOS. The secondary outcomes are percentage readmission, morbidity, mortality, hospital costs, long-term incidence of incisional hernias, residual stone rate, and recurrence of calculus. It will be assumed that, in patients undergoing LLH, the length of hospital stay will be reduced by 1 day. A sample size of 86 patients in each randomization arm has been calculated as sufficient to detect a 1-day reduction in LOS [90% power and α = 0.05 (two-tailed)]. The trial is a randomized controlled trial that will provide evidence for the merits of laparoscopic surgery in patients undergoing liver resection within an ERAS programme. CONCLUSIONS Although the outcomes of LLH have been proven to be comparable to those of OLH in retrospective studies, the use of LLH remains restricted, partly due to the lack of short- and long-term informative RCTs pertaining to patients with hepatolithiasis in ERAS programmes. To evaluate the surgical and long-term outcomes of LLH, we will perform a prospective RCT to compare LLH with OLH for hepatolithiasis within an ERAS programme. TRIAL REGISTRATION ClinicalTrials.gov NCT03958825. Registered on 21 May 2019.
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Affiliation(s)
- Shu-Bo Pan
- Department of General Surgery, The Second Affiliated Hospital of Anhui Medical University, Furong Road 678#, Shushan District, Hefei, 230601, Anhui, China
| | - Chun-Li Wu
- Department of General Surgery, The Second Affiliated Hospital of Anhui Medical University, Furong Road 678#, Shushan District, Hefei, 230601, Anhui, China
| | - Da-Chen Zhou
- Department of General Surgery, The Second Affiliated Hospital of Anhui Medical University, Furong Road 678#, Shushan District, Hefei, 230601, Anhui, China
| | - Qi-Ru Xiong
- Department of General Surgery, The Second Affiliated Hospital of Anhui Medical University, Furong Road 678#, Shushan District, Hefei, 230601, Anhui, China
| | - Xiao-Ping Geng
- Department of General Surgery, The Second Affiliated Hospital of Anhui Medical University, Furong Road 678#, Shushan District, Hefei, 230601, Anhui, China
| | - Hui Hou
- Department of General Surgery, The Second Affiliated Hospital of Anhui Medical University, Furong Road 678#, Shushan District, Hefei, 230601, Anhui, China.
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Manivasagam SS, Chandra J N. Comparison of Laparoscopic and Open Pancreaticoduodenectomy on Operative Time, Oncological Outcomes, Bleeding, Morbidity, and Mortality. Cureus 2024; 16:e53387. [PMID: 38435141 PMCID: PMC10908422 DOI: 10.7759/cureus.53387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2024] [Indexed: 03/05/2024] Open
Abstract
Laparoscopic pancreaticoduodenectomy (LPD) has gained popularity as an alternative to open pancreaticoduodenectomy (OPD), but comparative outcomes remain debated. The objective is to perform a systematic review and meta-analysis comparing LPD and OPD on operative time, oncologic outcomes, bleeding, morbidity, and mortality. The inclusion criteria were comparative studies on LPD vs. OPD. Outcomes were pooled using random-effects meta-analysis. A total of 27 studies were included, and LPD had a substantially longer operative duration compared to the OPD procedure, with a mean increase of 56 minutes, but blood loss was reduced by an average of 123 mL in patients who underwent LPD. Morbidity, mortality, margin status, and lymph node yields were similar between LPD and OPD. This study found comparable oncologic outcomes between LPD and OPD. LPD appears safe but requires longer operative time. High-quality randomized trials are still needed.
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Affiliation(s)
| | - Nemi Chandra J
- General Surgery, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, IND
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de Graaf N, Emmen AMLH, Ramera M, Björnsson B, Boggi U, Bruna CL, Busch OR, Daams F, Ferrari G, Festen S, van Hilst J, D'Hondt M, Ielpo B, Keck T, Khatkov IE, Koerkamp BG, Lips DJ, Luyer MDP, Mieog JSD, Morelli L, Molenaar IQ, van Santvoort HC, Sprangers MAG, Ferrari C, Berkhof J, Maisonneuve P, Abu Hilal M, Besselink MG. Minimally invasive versus open pancreatoduodenectomy for pancreatic and peri-ampullary neoplasm (DIPLOMA-2): study protocol for an international multicenter patient-blinded randomized controlled trial. Trials 2023; 24:665. [PMID: 37828593 PMCID: PMC10571285 DOI: 10.1186/s13063-023-07657-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 09/16/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Minimally invasive pancreatoduodenectomy (MIPD) aims to reduce the negative impact of surgery as compared to open pancreatoduodenectomy (OPD) and is increasingly becoming part of clinical practice for selected patients worldwide. However, the safety of MIPD remains a topic of debate and the potential shorter time to functional recovery needs to be confirmed. To guide safe implementation of MIPD, large-scale international randomized trials comparing MIPD and OPD in experienced high-volume centers are needed. We hypothesize that MIPD is non-inferior in terms of overall complications, but superior regarding time to functional recovery, as compared to OPD. METHODS/DESIGN The DIPLOMA-2 trial is an international randomized controlled, patient-blinded, non-inferiority trial performed in 14 high-volume pancreatic centers in Europe with a minimum annual volume of 30 MIPD and 30 OPD. A total of 288 patients with an indication for elective pancreatoduodenectomy for pre-malignant and malignant disease, eligible for both open and minimally invasive approach, are randomly allocated for MIPD or OPD in a 2:1 ratio. Centers perform either laparoscopic or robot-assisted MIPD based on their surgical expertise. The primary outcome is the Comprehensive Complication Index (CCI®), measuring all complications graded according to the Clavien-Dindo classification up to 90 days after surgery. The sample size is calculated with the following assumptions: 2.5% one-sided significance level (α), 80% power (1-β), expected difference of the mean CCI® score of 0 points between MIPD and OPD, and a non-inferiority margin of 7.5 points. The main secondary outcome is time to functional recovery, which will be analyzed for superiority. Other secondary outcomes include post-operative 90-day Fitbit™ measured activity, operative outcomes (e.g., blood loss, operative time, conversion to open surgery, surgeon-reported outcomes), oncological findings in case of malignancy (e.g., R0-resection rate, time to adjuvant treatment, survival), postoperative outcomes (e.g., clinically relevant complications), healthcare resource utilization (length of stay, readmissions, intensive care stay), quality of life, and costs. Postoperative follow-up is up to 36 months. DISCUSSION The DIPLOMA-2 trial aims to establish the safety of MIPD as the new standard of care for this selected patient population undergoing pancreatoduodenectomy in high-volume centers, ultimately aiming for superior patient recovery. TRIAL REGISTRATION ISRCTN27483786. Registered on August 2, 2023.
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Affiliation(s)
- Nine de Graaf
- Department of General Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, 25123, Italy.
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands.
- Cancer Center Amsterdam, Amsterdam, the Netherlands.
| | - Anouk M L H Emmen
- Department of General Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, 25123, Italy
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Marco Ramera
- Department of General Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, 25123, Italy
| | | | - Ugo Boggi
- Department of Surgery, Universitá Di Pisa, Pisa, Italy
| | - Caro L Bruna
- Department of General Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, 25123, Italy
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Giovanni Ferrari
- Department of Surgery, Niguarda Ca'Granda Hospital, Milan, Italy
| | | | - Jony van Hilst
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, OLVG, Amsterdam, the Netherlands
| | | | | | - Tobias Keck
- Department of Surgery, UKSH Campus Lübeck, Lübeck, Germany
| | - Igor E Khatkov
- Department of Surgery, Moscow Clinical Scientific Center, Moscow, Russian Federation
| | | | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Misha D P Luyer
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, the Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Luca Morelli
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Mirjam A G Sprangers
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Clarissa Ferrari
- Department of General Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, 25123, Italy
| | - Johannes Berkhof
- Department of Epidemiology and Data Science, Amsterdam UMC, VU University, Amsterdam, the Netherlands
| | - Patrick Maisonneuve
- Division of Epidemiology and Biostatistics, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Mohammad Abu Hilal
- Department of General Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, 25123, Italy.
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands.
- Cancer Center Amsterdam, Amsterdam, the Netherlands.
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Mithany RH, Gerges F, Shahid MH, Abdallah S, Manasseh M, Abdelmaseeh M, Abdalla M, Elmahi E. Operative and Hepatic Function Outcomes of Laparoscopic vs. Open Liver Resection: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e47274. [PMID: 37859673 PMCID: PMC10584273 DOI: 10.7759/cureus.47274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2023] [Indexed: 10/21/2023] Open
Abstract
Liver resection is a pivotal treatment for various liver diseases, and the choice between laparoscopic (LR) and open (OR) methods is debatable. This study aims to compare their respective complications and hepatic outcomes comprehensively, providing critical insights to guide clinical decisions and optimize patient results. We conducted a comprehensive review across PubMed, SCOPUS, WOS, and the Cochrane Library until September 2023. Randomized controlled trials (RCTs) comparing laparoscopic (LR) and open (OR) liver resections were included. Data screening, extraction, and quality assessments utilized the Risk of Bias (ROB-2). We conducted our analysis using Review Manager (RevMan 5.4) software, and the data were presented as risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI). Our comprehensive research yielded 3,192 relevant records, and 9 RCTs were finally included. LR exhibited reduced operative bleeding (MD = -82.87 ml, 95% CI: -132.45 to -33.30, P=0.001) and shorter hospital stays (MD = -2.32 days, 95% CI: -3.65 to -0.98, P=0.0007). The risk of complications was significantly lower in the LR group (RR = 0.57, 95% CI: 0.43-0.76, P<0.0001), especially in Clavian-Dindo classification degree 1 and 2 complications (RR = 0.47, 95% CI: 0.28-0.79, P=0.005). LR patients also had lower postoperative AST levels at one day (MD = -123.16 U/L, 95% CI: -206.08 to -40.24, P=0.004) and three days (MD = -35.95 U/L, 95% CI: -65.83 to -6.06, P=0.02). These findings underscore LR's superiority, emphasizing its potential to significantly enhance patient outcomes, reduce complications, and improve recovery in liver resection procedures.
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Affiliation(s)
- Reda H Mithany
- Laparoscopic Colorectal Surgery, Kingston Hospital National Health Services (NHS) Foundation Trust, Kingston, GBR
| | - Farid Gerges
- General and Emergency Surgery, Kingston Hospital National Health Services (NHS) Foundation Trust, Kingston, GBR
| | | | | | - Mina Manasseh
- General Surgery, Torbay and South Devon National Health Services (NHS) Foundation Trust, Torquay, GBR
| | - Mark Abdelmaseeh
- General Surgery, Faculty of Medicine, Assuit University, Assuit, EGY
| | - Mazin Abdalla
- General Surgery, Kingston Hospital National Health Services (NHS) Foundation Trust, Kingston, GBR
| | - Eiad Elmahi
- General Surgery, Lincoln County Hospital, Lincoln, GBR
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8
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Coelho FF, Herman P, Kruger JAP, Wu AGR, Chin KM, Hasegawa K, Zhang W, Alzoubi M, Aghayan DL, Siow TF, Scatton O, Kingham TP, Marino MV, Mazzaferro V, Chiow AKH, Sucandy I, Ivanecz A, Choi SH, Lee JH, Gastaca M, Vivarelli M, Giuliante F, Ruzzenente A, Yong CC, Dokmak S, Fondevila C, Efanov M, Morise Z, Di Benedetto F, Brustia R, Valle RD, Boggi U, Geller D, Belli A, Memeo R, Gruttadauria S, Mejia A, Park JO, Rotellar F, Choi GH, Robles-Campos R, Wang X, Sutcliffe RP, Pratschke J, Lai ECH, Chong CCN, D'Hondt M, Monden K, Lopez-Ben S, Liu R, Ferrero A, Ettorre GM, Cipriani F, Cherqui D, Liang X, Soubrane O, Wakabayashi G, Troisi RI, Yin M, Cheung TT, Sugioka A, Han HS, Long TCD, Fuks D, Abu Hilal M, Chen KH, Aldrighetti L, Edwin B, Goh BKP. Impact of liver cirrhosis, the severity of cirrhosis, and portal hypertension on the outcomes of minimally invasive left lateral sectionectomies for primary liver malignancies. Surgery 2023; 174:581-592. [PMID: 37301612 PMCID: PMC10986843 DOI: 10.1016/j.surg.2023.04.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 04/08/2023] [Accepted: 04/27/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND The impact of cirrhosis and portal hypertension on perioperative outcomes of minimally invasive left lateral sectionectomies remains unclear. We aimed to compare the perioperative outcomes between patients with preserved and compromised liver function (noncirrhotics versus Child-Pugh A) when undergoing minimally invasive left lateral sectionectomies. In addition, we aimed to determine if the extent of cirrhosis (Child-Pugh A versus B) and the presence of portal hypertension had a significant impact on perioperative outcomes. METHODS This was an international multicenter retrospective analysis of 1,526 patients who underwent minimally invasive left lateral sectionectomies for primary liver malignancies at 60 centers worldwide between 2004 and 2021. In the study, 1,370 patients met the inclusion criteria and formed the final study group. Baseline clinicopathological characteristics and perioperative outcomes of these patients were compared. To minimize confounding factors, 1:1 propensity score matching and coarsened exact matching were performed. RESULTS The study group comprised 559, 753, and 58 patients who did not have cirrhosis, Child-Pugh A, and Child-Pugh B cirrhosis, respectively. Six-hundred and thirty patients with cirrhosis had portal hypertension, and 170 did not. After propensity score matching and coarsened exact matching, Child-Pugh A patients with cirrhosis undergoing minimally invasive left lateral sectionectomies had longer operative time, higher intraoperative blood loss, higher transfusion rate, and longer hospital stay than patients without cirrhosis. The extent of cirrhosis did not significantly impact perioperative outcomes except for a longer duration of hospital stay. CONCLUSION Liver cirrhosis adversely affected the intraoperative technical difficulty and perioperative outcomes of minimally invasive left lateral sectionectomies.
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Affiliation(s)
- Fabricio Ferreira Coelho
- Department of Gastroenterology, Liver Surgery Unit, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Paulo Herman
- Department of Gastroenterology, Liver Surgery Unit, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Jaime A P Kruger
- Department of Gastroenterology, Liver Surgery Unit, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Andrew G R Wu
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ken-Min Chin
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Wanguang Zhang
- Hepatic Surgery Center and Hubei Key Laboratory of Hepato-Biliary-Pancreatic Diseases, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | | | - Davit L Aghayan
- The Intervention Centre and Department of HPB Surgery, Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Tiing-Foong Siow
- Division of General Surgery, Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Olivier Scatton
- Department of Digestive, HBP and Liver Transplantation, Hopital Pitie-Salpetriere, Sorbonne Universite, Paris, France
| | - T Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Marco V Marino
- General Surgery Department, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy and General Surgery Department, F Tappeiner Hospital, Merano, Italy
| | - Vincenzo Mazzaferro
- HPB Surgery and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano and University of Milan, Italy
| | - Adrian K H Chiow
- Hepatopancreatobiliary Unit, Department of Surgery, Changi General Hospital, Singapore
| | | | - Arpad Ivanecz
- Department of Abdominal and General Surgery, University Medical Center Maribor, Maribor, Slovenia
| | - Sung Hoon Choi
- Department of General Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Jae Hoon Lee
- Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Mikel Gastaca
- Hepatobiliary Surgery and Liver Transplantation Unit, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, University of the Basque Country, Bilbao, Spain
| | - Marco Vivarelli
- HPB Surgery and Transplantation Unit, United Hospital of Ancona, Department of Experimental and Clinical Medicine Polytechnic University of Marche, Ancona, Italy
| | - Felice Giuliante
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Andrea Ruzzenente
- General and Hepatobiliary Surgery, Department of Surgery, Dentistry, Gynecology and Pediatrics University of Verona, GB Rossi Hospital, Verona, Italy
| | - Chee-Chien Yong
- Department of Surgery, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Safi Dokmak
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, University Paris Cite, Clichy, France
| | - Constantino Fondevila
- General and Digestive Surgery, Hospital Clinic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain and General and Digestive Surgery, Hospital Universitario La Paz, IdiPAZ, CIBERehd, Madrid, Spain
| | - Mikhail Efanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, Moscow, Russia
| | - Zenichi Morise
- Department of Surgery, Okazaki Medical Center, Fujita Health University School of Medicine, Okazaki, Japan
| | - Fabrizio Di Benedetto
- HPB Surgery and Liver Transplant Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Raffaele Brustia
- Department of Digestive and Hepatobiliary and Pancreatic Surgery, AP-HP, Henri-Mondor Hospital, Creteil, France
| | - Raffaele Dalla Valle
- Hepatobiliary Surgery Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - David Geller
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, University of Pittsburgh Medical Center, PA, USA
| | - Andrea Belli
- Department of Abdominal Oncology, Division of Hepatopancreatobiliary Surgical Oncology, National Cancer Center-IRCCS-G. Pascale, Naples, Italy
| | - Riccardo Memeo
- Unit of Hepato-Pancreatc-Biliary Surgery, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Salvatore Gruttadauria
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (IRCCS-ISMETT), University of Pittsburgh Medical Center Italy, Palermo, Italy; Department of General Surgery and Medical Surgical Specialties, University of Catania, Italy
| | | | - James O Park
- Department of Surgery, University of Washington Medical Center, Seattle, WA
| | - Fernando Rotellar
- HPB and Liver Transplant Unit, Department of General Surgery, Clinica Universidad de Navarra, Universidad de Navarra, Pamplona, Spain & Institute of Health Research of Navarra (IdisNA), Pamplona, Spain
| | - Gi Hong Choi
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ricardo Robles-Campos
- Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain
| | - Xiaoying Wang
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Robert P Sutcliffe
- Department of Hepatopancreatobiliary and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, United Kingdom
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Corporate Member of Freie Universität Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Eric C H Lai
- Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
| | - Charing C N Chong
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, New Territories, China
| | - Mathieu D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - Kazuteru Monden
- Department of Surgery, Fukuyama City Hospital, Hiroshima, Japan
| | - Santiago Lopez-Ben
- Hepatobiliary and Pancreatic Surgery Unit, Department of Surgery, Dr. Josep Trueta Hospital, IdIBGi, Girona, Spain
| | - Rong Liu
- Faculty of Hepatopancreatobiliary Surgery, the First Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Alessandro Ferrero
- Department of General and Oncological Surgery, Mauriziano Hospital, Turin, Italy
| | - Giuseppe Maria Ettorre
- Division of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Federica Cipriani
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - Daniel Cherqui
- Department of Hepatobiliary Surgery, Assistance Publique Hopitaux de Paris, Centre Hepato-Biliaire, Paul-Brousse Hospital, Villejuif, France
| | - Xiao Liang
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Olivier Soubrane
- Department of Digestive, Oncologic and Metabolic Surgery, Institute Mutualiste Montsouris, Universite Paris Descartes, Paris, France
| | - Go Wakabayashi
- Center for Advanced Treatment of Hepatobiliary and Pancreatic Diseases, Ageo Central General Hospital, Saitama, Japan
| | - Roberto I Troisi
- Department of Clinical Medicine and Surgery, Division of HPB, Minimally Invasive and Robotic Surgery, Federico II University Hospital, Naples, Italy
| | - Mengqiu Yin
- Department of Hepatobiliary Surgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China
| | - Tan-To Cheung
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, China
| | - Atsushi Sugioka
- Department of Surgery, Fujita Health University School of Medicine, Aichi, Japan
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Hospital Bundang, Seoul National University College of Medicine, Seoul, Korea
| | - Tran Cong Duy Long
- Department of Hepatopancreatobiliary Surgery, University Medical Center, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - David Fuks
- Department of Digestive, Oncologic and Metabolic Surgery, Institute Mutualiste Montsouris, Universite Paris Descartes, Paris, France
| | - Mohammad Abu Hilal
- Department of Surgery, Fondazione Poliambulanza, Brescia, Italy; Department of Surgery, University Hospital Southampton, Southampton, United Kingdom
| | - Kuo-Hsin Chen
- Division of General Surgery, Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - Bjørn Edwin
- The Intervention Centre and Department of HPB Surgery, Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore; Duke National University of Singapore Medical School, Singapore.
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9
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Wang M, Qin T, Zhang H, Li J, Deng X, Zhang Y, Zhao W, Fan Y, Li D, Chen X, Feng Y, Zhu S, Xing Z, Yu G, Xu J, Xie J, Dou C, Ma H, Liu G, Shao Y, Chen W, Liu J, Liu J, Yin X, Qin R. Laparoscopic versus open surgery for perihilar cholangiocarcinoma: a multicenter propensity score analysis of short- term outcomes. BMC Cancer 2023; 23:394. [PMID: 37138243 PMCID: PMC10157952 DOI: 10.1186/s12885-023-10783-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 03/28/2023] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND Laparoscopic surgery (LS) has been increasingly applied in perihilar cholangiocarcinoma (pCCA). In this study, we intend to compare the short-term outcomes of LS versus open operation (OP) for pCCA in a multicentric practice in China. METHODS This real-world analysis included 645 pCCA patients receiving LS and OP at 11 participating centers in China between January 2013 and January 2019. A comparative analysis was performed before and after propensity score matching (PSM) in LS and OP groups, and within Bismuth subgroups. Univariate and multivariate models were performed to identify significant prognostic factors of adverse surgical outcomes and postoperative length of stay (LOS). RESULTS Among 645 pCCAs, 256 received LS and 389 received OP. Reduced hepaticojejunostomy (30.89% vs 51.40%, P = 0.006), biliary plasty requirement (19.51% vs 40.16%, P = 0.001), shorter LOS (mean 14.32 vs 17.95 d, P < 0.001), and lower severe complication (CD ≥ III) (12.11% vs. 22.88%, P = 0.006) were observed in the LS group compared with the OP group. Major postoperative complications such as hemorrhage, biliary fistula, abdominal abscess, and hepatic insufficiency were similar between LS and OP (P > 0.05 for all). After PSM, the short-term outcomes of two surgical methods were similar, except for shorter LOS in LS compared with OP (mean 15.19 vs 18.48 d, P = 0.0007). A series subgroup analysis demonstrated that LS was safe and had advantages in shorting LOS. CONCLUSION Although the complex surgical procedures, LS generally seems to be safe and feasible for experienced surgeons. TRIAL REGISTRATION NCT05402618 (date of first registration: 02/06/2022).
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Affiliation(s)
- Min Wang
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Tingting Qin
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Hang Zhang
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Jingdong Li
- Department of Hepatobiliary Surgery, Affiliated Hospital of North Sichuan Medical College, Hepatobiliary, Pancreatic and Intestinal Diseases Research Institute of North Sichuan Medical College, Nanchong, 637000, China
| | - Xiaxing Deng
- Department of Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 310000, China
| | - Yuhua Zhang
- Department of Hepatobiliary, Pancreatic and Minimal Invasive Surgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, 310003, China
| | - Wenxing Zhao
- Department of General Surgery, the Affiliated Hospital of Xuzhou Medical University Xuzhou, Jiangsu, 221000, China
| | - Ying Fan
- Department of the Second General Surgery, Sheng Jing Hospital of China Medical University, Liaoning, 110000, China
| | - Dewei Li
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Xuemin Chen
- Department of Hepatopancreatobiliary Surgery, Third Affiliated Hospital of Soochow University, Suzhou, 213003, China
| | - Yechen Feng
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Siwei Zhu
- Department of Hepatobiliary Surgery, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005, Hunan, China
| | - Zhongqiang Xing
- Department of Hepato-Pancreato-Biliary Surgery, the Second Hospital of Hebei Medical University, Shijiazhuang, 050017, Hebei, China
| | - Guangsheng Yu
- Shandong Provincial Institute of Dermatology and Venereology, Shandong Academy of Medical Sciences, 27397 Jingshi Road, Jinan, 250022, China
| | - Jian Xu
- Department of Hepatobiliary Surgery, Affiliated Hospital of North Sichuan Medical College, Hepatobiliary, Pancreatic and Intestinal Diseases Research Institute of North Sichuan Medical College, Nanchong, 637000, China
| | - Junjie Xie
- Department of Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 310000, China
| | - Changwei Dou
- Department of Hepatobiliary, Pancreatic and Minimal Invasive Surgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, 310003, China
| | - Hongqin Ma
- Department of General Surgery, the Affiliated Hospital of Xuzhou Medical University Xuzhou, Jiangsu, 221000, China
| | - Gangshan Liu
- Department of the Second General Surgery, Sheng Jing Hospital of China Medical University, Liaoning, 110000, China
| | - Yue Shao
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Weibo Chen
- Department of Hepatopancreatobiliary Surgery, Third Affiliated Hospital of Soochow University, Suzhou, 213003, China
| | - Jun Liu
- Shandong Provincial Institute of Dermatology and Venereology, Shandong Academy of Medical Sciences, 27397 Jingshi Road, Jinan, 250022, China.
| | - Jianhua Liu
- Department of Hepato-Pancreato-Biliary Surgery, the Second Hospital of Hebei Medical University, Shijiazhuang, 050017, Hebei, China.
| | - Xinmin Yin
- Department of Hepatobiliary Surgery, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, 410005, Hunan, China.
| | - Renyi Qin
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.
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10
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Lancellotti F, Coletta D, de'Liguori Carino N, Satyadas T, Jegatheeswaran S, Maruccio M, Sheen AJ, Siriwardena AK, Jamdar S. Venous thromboembolism (VTE) after open hepatectomy compared to minimally invasive liver resection: a systematic review and meta-analysis. HPB (Oxford) 2023:S1365-182X(23)00129-6. [PMID: 37169670 DOI: 10.1016/j.hpb.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Even though the risk of postoperative venous thromboembolism (VTE) after liver resection is well recognized, the association between surgical approach and VTE risk is unknown. This study aims to compare VTE rates following open liver resection (OLR) and minimally invasive liver resection (MILR). METHODS MEDLINE, Web Of Sciences and EMBASE databases were interrogated to identify eligible studies published between February 2016 and August 2022. Studies were considered suitable if they reported a comparison between OLR and MILR (including laparoscopic liver resection [LLR] or robotic liver resection [RLR]). RESULTS Fourteen studies including 11 356 patients met the inclusion criteria. 5622 patients underwent OLR and 5734 patients underwent MILR. The VTE rate was higher among patients who underwent OLR compared to MILR (2.8% vs 1.4%, OR (95% CI) = 1.84, p=<00001). Similarly, the subgroup analysis showed a higher rate of deep venous thrombosis (DVT) (1.4% vs 0.7%, OR (95% CI) = 1.98, p = 0.02) and pulmonary embolism (PE) (1.3% vs 0.7%, OR (95% CI) = 1.88, p = 0.002) in patients who underwent OLR compared to MILR. DISCUSSION Patients who undergo open hepatectomy have a higher incidence of postoperative VTE when compared to those undergoing minimally invasive liver resection. This finding was consistent for both DVT and PE.
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Affiliation(s)
- Francesco Lancellotti
- Hepatobiliary and Pancreatic Surgery Unit, Manchester University NHS FT, Manchester, M13 9WL, UK
| | - Diego Coletta
- Department of General Surgery, Ospedali Riuniti Marche Nord, Pesaro, Italy; Department of Surgical Sciences, Umberto I University Hospital, Sapienza University of Rome, Rome, Italy
| | - Nicola de'Liguori Carino
- Hepatobiliary and Pancreatic Surgery Unit, Manchester University NHS FT, Manchester, M13 9WL, UK
| | - Thomas Satyadas
- Hepatobiliary and Pancreatic Surgery Unit, Manchester University NHS FT, Manchester, M13 9WL, UK
| | | | - Martina Maruccio
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Aali J Sheen
- Hepatobiliary and Pancreatic Surgery Unit, Manchester University NHS FT, Manchester, M13 9WL, UK
| | - Ajith K Siriwardena
- Hepatobiliary and Pancreatic Surgery Unit, Manchester University NHS FT, Manchester, M13 9WL, UK
| | - Saurabh Jamdar
- Hepatobiliary and Pancreatic Surgery Unit, Manchester University NHS FT, Manchester, M13 9WL, UK.
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11
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Maibom SL, Joensen UN, Aasvang EK, Rohrsted M, Thind PO, Bagi P, Kistorp T, Poulsen AM, Salling LN, Kehlet H, Brasso K, Røder MA. Robot-assisted laparoscopic radical cystectomy with intracorporeal ileal conduit diversion versus open radical cystectomy with ileal conduit for bladder cancer in an ERAS setup (BORARC): protocol for a single-centre, double-blinded, randomised feasibility study. Pilot Feasibility Stud 2023; 9:7. [PMID: 36639814 PMCID: PMC9838067 DOI: 10.1186/s40814-022-01229-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 12/16/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Radical cystectomy (RC) with urinary diversion is the recommended treatment for selected cases of non-metastatic high-risk non-muscle-invasive and muscle-invasive bladder cancer. It remains unknown whether robot-assisted laparoscopic cystectomy (RARC) offers any advantage in terms of safety compared to open cystectomy (ORC) in an Enhanced Recovery After Surgery (ERAS) setup. Blinded randomised controlled trials (RCTs) between RARC versus ORC have never been conducted in cystectomy patients. We will investigate the feasibility of conducting a double-blinded RCT comparing ORC with RARC with intra-corporal ileal conduit (iRARC) in an ERAS setup. METHODS This is a single-centre, double-blinded, randomised (1:1) clinical feasibility study for patients with non-metastatic high-risk non-muscle-invasive or muscle-invasive bladder cancer scheduled for cystectomy. All participants are recruited from Rigshospitalet, Denmark. The planned sample size is 50 participants to investigate whether blinding of the surgical technique is feasible. Participants and postoperative caring physicians and nurses are blinded using a pre-study designed abdominal dressing and blinding of the patient's electronic health record. Study endpoints are assessed 90 days postoperatively. The primary aim is to study the frequency and pattern of unplanned unblinding after surgery and the number of participants who cannot guess the surgical technique at the day of discharge. Eleven secondary endpoints are assessed: length of stay, days alive and out of hospital, in-hospital complication rate, 30-day complication rate, 90-day complication rate, readmission rate, quality of life, blood loss, pain, rate of moderate/severe post-anaesthesia care unit (PACU) complications, and delirium. Participants are managed in an ERAS setup in both arms of the trial. DISCUSSION We report on the design and objectives of a novel experimental feasibility study investigating whether blinding of the surgical technique in cystectomy patients is possible. This information is essential for the design of future blinded trials comparing ORC to RARC. There is a continued need to compare RARC and ORC in terms of both efficacy, safety, and oncological outcomes. Estimated end of study is March 2021. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT03977831. Registered on the 6th of June 2019.
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Affiliation(s)
- Sophia Liff Maibom
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Ulla Nordström Joensen
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Eske Kvanner Aasvang
- grid.5254.60000 0001 0674 042XDepartment of Anaesthesiology, Centre for Cancer and Organ Diseases, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Malene Rohrsted
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Peter Ole Thind
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Per Bagi
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Thomas Kistorp
- grid.5254.60000 0001 0674 042XDepartment of Anaesthesiology, Centre for Cancer and Organ Diseases, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Alicia Martin Poulsen
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Lisbeth Nerstrøm Salling
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Henrik Kehlet
- grid.5254.60000 0001 0674 042XSection of Surgical Pathophysiology, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Klaus Brasso
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Martin Andreas Røder
- grid.5254.60000 0001 0674 042XUrological Research Unit, Department of Urology, Faculty of Health and Medical Sciences, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
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12
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Lo WM, Tohme ST, Geller DA. Recent Advances in Minimally Invasive Liver Resection for Colorectal Cancer Liver Metastases-A Review. Cancers (Basel) 2022; 15:cancers15010142. [PMID: 36612137 PMCID: PMC9817853 DOI: 10.3390/cancers15010142] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/29/2022] [Accepted: 12/02/2022] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
| | | | - David A. Geller
- Correspondence: ; Tel.: +1-412-692-2001; Fax: +1-412-602-2002
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13
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Impact of Frailty on Short-Term Outcomes After Laparoscopic and Open Hepatectomy. World J Surg 2022; 46:2444-2453. [PMID: 35810214 PMCID: PMC9436876 DOI: 10.1007/s00268-022-06648-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2022] [Indexed: 11/27/2022]
Abstract
Background Although laparoscopic hepatectomy (LH) is associated with improved short-term outcomes compared to open hepatectomy (OH), it is unknown whether frail patients also benefit from LH. The aim of this study was to evaluate the impact of frailty on post-operative outcomes after LH and OH. Patients and methods Consecutive patients who underwent LH and OH between January 2011 and December 2018 were identified from a prospective database. Frailty was assessed using the modified Frailty Index (mFI), with patients scoring mFI ≥ 1 deemed to be frail. Results Of 1826 patients, 34.7% (N = 634) were frail and 18.6% (N = 340) were elderly (≥ 75 years). Frail patients had significantly higher 90-day mortality (6.6% vs. 2.9%, p < 0.001) and post-operative complications (36.3% vs. 26.1%, p < 0.001) than those who were not frail, effects that were independent of patient age on multivariate analysis. For those undergoing minor resections, the benefits of LH vs. OH were similar for frail and non-frail patients. Length of hospital stay was 53% longer in OH (vs. LH) in frail patients, compared to 58% longer in the subgroup of non-frail patients. Conclusions Frailty is independently associated with inferior post-operative outcomes in patients undergoing hepatectomy. However, the benefits of laparoscopic (compared to open) hepatectomy are similar for frail and non-frail patients. Frailty should not be a contraindication to laparoscopic minor hepatectomy in carefully selected patients.
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14
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Peng Y, Chen K, Li B, Xu H, Wei Y, Liu F. Laparoscopic versus open liver resection for resectable HCC with BCLC stage B: a propensity score-matched analysis. Updates Surg 2022; 74:1291-1297. [PMID: 35739381 DOI: 10.1007/s13304-022-01309-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 05/30/2022] [Indexed: 02/05/2023]
Abstract
To date, there is little knowledge about the value of laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) patients with Barcelona Clinic Liver Cancer (BCLC) stage B. Thus, this study was performed to assess the perioperative and oncological outcomes of LLR for these patients by comparison with open liver resection (OLR). Between April 2015 and October 2018, a total of 217 resectable HCC patients with BCLC stage B were eligible for this study. Patients were divided into the LLR group and the OLR group according to different procedures. Propensity score matching (PSM) was conducted to adjust for known confounders. Short- and long-term outcomes were compared between the two groups. LLR was performed in 75 of the 217 included patients. After PSM, 72 patients with well-balanced baseline levels were enrolled into each group. Although the operative time was significantly longer in the LLR group than in the OLR group (median, 237.5 vs. 210 min, P = 0.024), the intraoperative blood loss was significantly less in the LLR group than in the OLR group (median, 200 vs. 350 ml, P = 0.005). Patients in the LLR group had fewer complications than those in the OLR group (P = 0.035). Furthermore, overall survival (OS, P = 0.827) and recurrence-free survival (RFS, P = 0.694) were comparable between the two groups. LLR for resectable HCC patients with BCLC stage B is safe and feasible in carefully selected patients and has superior perioperative outcomes and similar survival rates compared with OLR.
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Affiliation(s)
- Yufu Peng
- Department of Liver Surgery, Center of Liver Transplantation, West China Hospital of Sichuan University, No. 37 Guoxuexiang, Chengdu, Sichuan Province, China
| | - Kefei Chen
- Department of Liver Surgery, Center of Liver Transplantation, West China Hospital of Sichuan University, No. 37 Guoxuexiang, Chengdu, Sichuan Province, China
| | - Bo Li
- Department of Liver Surgery, Center of Liver Transplantation, West China Hospital of Sichuan University, No. 37 Guoxuexiang, Chengdu, Sichuan Province, China
| | - Hongwei Xu
- Department of Liver Surgery, Center of Liver Transplantation, West China Hospital of Sichuan University, No. 37 Guoxuexiang, Chengdu, Sichuan Province, China
| | - Yonggang Wei
- Department of Liver Surgery, Center of Liver Transplantation, West China Hospital of Sichuan University, No. 37 Guoxuexiang, Chengdu, Sichuan Province, China.
| | - Fei Liu
- Department of Liver Surgery, Center of Liver Transplantation, West China Hospital of Sichuan University, No. 37 Guoxuexiang, Chengdu, Sichuan Province, China.
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15
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Kuemmerli C, Fichtinger RS, Moekotte A, Aldrighetti LA, Aroori S, Besselink MGH, D’Hondt M, Díaz-Nieto R, Edwin B, Efanov M, Ettorre GM, Menon KV, Sheen AJ, Soonawalla Z, Sutcliffe R, Troisi RI, White SA, Brandts L, van Breukelen GJP, Sijberden J, Pugh SA, Eminton Z, Primrose JN, van Dam R, Hilal MA. Laparoscopic versus open resections in the posterosuperior liver segments within an enhanced recovery programme (ORANGE Segments): study protocol for a multicentre randomised controlled trial. Trials 2022; 23:206. [PMID: 35264216 PMCID: PMC8908665 DOI: 10.1186/s13063-022-06112-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 02/15/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND A shift towards parenchymal-sparing liver resections in open and laparoscopic surgery emerged in the last few years. Laparoscopic liver resection is technically feasible and safe, and consensus guidelines acknowledge the laparoscopic approach in the posterosuperior segments. Lesions situated in these segments are considered the most challenging for the laparoscopic approach. The aim of this trial is to compare the postoperative time to functional recovery, complications, oncological safety, quality of life, survival and costs after laparoscopic versus open parenchymal-sparing liver resections in the posterosuperior liver segments within an enhanced recovery setting. METHODS The ORANGE Segments trial is an international multicentre randomised controlled superiority trial conducted in centres experienced in laparoscopic liver resection. Eligible patients for minor resections in the posterosuperior segments will be randomised in a 1:1 ratio to undergo laparoscopic or open resections in an enhanced recovery setting. Patients and ward personnel are blinded to the treatment allocation until postoperative day 4 using a large abdominal dressing. The primary endpoint is time to functional recovery. Secondary endpoints include intraoperative outcomes, length of stay, resection margin, postoperative complications, 90-day mortality, time to adjuvant chemotherapy initiation, quality of life and overall survival. Laparoscopic liver surgery of the posterosuperior segments is hypothesised to reduce time to functional recovery by 2 days in comparison with open surgery. With a power of 80% and alpha of 0.04 to adjust for interim analysis halfway the trial, a total of 250 patients are required to be randomised. DISCUSSION The ORANGE Segments trial is the first multicentre international randomised controlled study to compare short- and long-term surgical and oncological outcomes of laparoscopic and open resections in the posterosuperior segments within an enhanced recovery programme. TRIAL REGISTRATION ClinicalTrials.gov NCT03270917 . Registered on September 1, 2017. Before start of inclusion. PROTOCOL VERSION version 12, May 9, 2017.
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Affiliation(s)
- Christoph Kuemmerli
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD UK
- Department of Surgery, Foundation Poliambulanza, Via Bissolati, Brescia, Italy
| | - Robert S. Fichtinger
- Department of Surgery, Maastricht University Medical Centre+, 6202 AZ Maastricht, The Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Alma Moekotte
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD UK
| | | | - Somaiah Aroori
- Peninsula HPB Unit, Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Marc G. H. Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Mathieu D’Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - Rafael Díaz-Nieto
- Hepatobiliary Surgery Unit, Aintree University Hospital, Liverpool, UK
| | - Bjørn Edwin
- Department of HPB Surgery, Oslo University Hospital, Oslo, Norway
| | - Mikhail Efanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Centre, Moscow, Russia
| | - Giuseppe M. Ettorre
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
| | | | - Aali J. Sheen
- Department of Surgery, Manchester University Foundation Trust, Manchester, UK
| | - Zahir Soonawalla
- Department of Surgery, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Robert Sutcliffe
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
| | - Roberto I. Troisi
- Division of HPB, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Steven A. White
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Lloyd Brandts
- Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht UMC+, Maastricht, The Netherlands
| | - Gerard J. P. van Breukelen
- Department of Methodology and Statistics, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jasper Sijberden
- Department of Surgery, Foundation Poliambulanza, Via Bissolati, Brescia, Italy
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Siân A. Pugh
- Department of Oncology, Addenbrooke’s Hospital, Cambridge, UK
| | - Zina Eminton
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - John N. Primrose
- Department of Surgery, University of Southampton, Southampton, UK
| | - Ronald van Dam
- Department of Surgery, Maastricht University Medical Centre+, 6202 AZ Maastricht, The Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- GROW – School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Mohammed Abu Hilal
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD UK
- Department of Surgery, Foundation Poliambulanza, Via Bissolati, Brescia, Italy
| | - on behalf of the ORANGE trials collaborative
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD UK
- Department of Surgery, Foundation Poliambulanza, Via Bissolati, Brescia, Italy
- Department of Surgery, Maastricht University Medical Centre+, 6202 AZ Maastricht, The Netherlands
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
- Peninsula HPB Unit, Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
- Hepatobiliary Surgery Unit, Aintree University Hospital, Liverpool, UK
- Department of HPB Surgery, Oslo University Hospital, Oslo, Norway
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Research Centre, Moscow, Russia
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
- Institute of Liver Studies, Kings College Hospital, London, UK
- Department of Surgery, Manchester University Foundation Trust, Manchester, UK
- Department of Surgery, Oxford University Hospital NHS Foundation Trust, Oxford, UK
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals Birmingham, NHS Foundation Trust, Birmingham, UK
- Division of HPB, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
- Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht UMC+, Maastricht, The Netherlands
- Department of Methodology and Statistics, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Oncology, Addenbrooke’s Hospital, Cambridge, UK
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
- Department of Surgery, University of Southampton, Southampton, UK
- GROW – School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
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16
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Jin J, Shi Y, Chen M, Qian J, Qin K, Wang Z, Chen W, Jin W, Lu F, Li Z, Wu Z, Jian L, Han B, Liang X, Sun C, Wu Z, Mou Y, Yin X, Huang H, Chen H, Gemenetzis G, Deng X, Peng C, Shen B. Robotic versus Open Pancreatoduodenectomy for Pancreatic and Periampullary Tumors (PORTAL): a study protocol for a multicenter phase III non-inferiority randomized controlled trial. Trials 2021; 22:954. [PMID: 34961558 PMCID: PMC8711152 DOI: 10.1186/s13063-021-05939-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 12/15/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Pancreatoduodenectomy is a complex and challenging procedure that requires meticulous tissue dissection and proficient suturing skills. Minimally invasive surgery with the utilization of robotic platforms has demonstrated advantages in perioperative patient outcomes in retrospective studies. The development of robotic pancreatoduodenectomy (RPD) in specific has progressed significantly, since first reported in 2003, and high-volume centers in pancreatic surgery are reporting large patient series with improved pain management and reduced length of stay. However, prospective studies to assess objectively the feasibility and safety of RPD compared to open pancreatoduodenectomy (OPD) are currently lacking. METHODS/DESIGN The PORTAL trial is a multicenter randomized controlled, patient-blinded, parallel-group, phase III non-inferiority trial performed in seven high-volume centers for pancreatic and robotic surgery in China (> 20 RPD and > 100 OPD annually in each participating center). The trial is designed to enroll and randomly assign 244 patients with an indication for elective pancreatoduodenectomy for malignant periampullary and pancreatic lesions, as well as premalignant and symptomatic benign periampullary and pancreatic disease. The primary outcome is time to functional recovery postoperatively, measured in days. Secondary outcomes include postoperative morbidity and mortality, as well as perioperative costs. A sub-cohort of 128 patients with pancreatic adenocarcinoma (PDAC) will also be compared to assess the percentage of patients who undergo postoperative adjuvant chemotherapy within 8 weeks, in each arm. Secondary outcomes in this cohort will include patterns of disease recurrence, recurrence-free survival, and overall survival. DISCUSSION The PORTAL trial is designed to assess the feasibility and safety of RPD compared to OPD, in terms of functional recovery as described previously. Additionally, this trial will explore whether RPD allows increased access to postoperative adjuvant chemotherapy, in a sub-cohort of patients with PDAC. TRIAL REGISTRATION ClinicalTrials.gov NCT04400357 . Registered on May 22, 2020.
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Affiliation(s)
- Jiabin Jin
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yusheng Shi
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mengmin Chen
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianfeng Qian
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kai Qin
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhen Wang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi Province, China
| | - Wei Chen
- Department of Pancreaticobiliary Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Weiwei Jin
- Department of Gastroenterology and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang Province, China
| | - Fengchun Lu
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Zheyong Li
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Zehua Wu
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Li Jian
- Clinical Research Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bing Han
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Xiao Liang
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Chuandong Sun
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Zheng Wu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi Province, China
| | - Yiping Mou
- Department of Gastroenterology and Pancreatic Surgery, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang Province, China
| | - Xiaoyu Yin
- Department of Pancreaticobiliary Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Heguang Huang
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Hao Chen
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Georgios Gemenetzis
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Department of Hepatopancreatobiliary and Transplant Surgery, Royal Infirmary Edinburgh, Edinburgh, UK.
- Department of Pancreatobiliary Surgery, Glasgow Royal Infirmary, Glasgow, UK.
| | - Xiaxing Deng
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Chenghong Peng
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Baiyong Shen
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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17
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Kowalewski KF, Sidoti Abate MA, Neuberger M, Kirchner M, Krisam R, Egen L, Haney CM, Siegel F, Michel MS, Honeck P, Nuhn P, Westhoff N, Kriegmair MC. ROBOCOP II (ROBOtic assisted versus conventional open partial nephrectomy) randomised, controlled feasibility trial: clinical trial protocol. BMJ Open 2021; 11:e052087. [PMID: 34732486 PMCID: PMC8572388 DOI: 10.1136/bmjopen-2021-052087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
INTRODUCTION Randomised controlled trials comparing robotic-assisted partial nephrectomy (RAPN) and open PN (OPN) are lacking. Therefore, we aim to report the study protocol and a trial update for a randomised controlled feasibility trial comparing RAPN versus OPN for renal neoplasms. METHODS AND ANALYSIS The ROBOtic assisted versus conventional Open Partial nephrectomy II trial is designed as a single-centre, randomised, open-label, feasibility trial. Participation will be offered to patients with renal neoplasms and deemed feasible for both, OPN and RAPN. We aim to enrol 50 patients within 15 months using a 1:1 allocation ratio. The primary endpoint of the trial is feasibility of recruitment and will be successful if one third of eligible patients agree to participate. Secondary endpoints include perioperative results, health-related quality of life, inflammatory response as well as surgical ergonomics of the operating team. If the primary outcome, feasibility of recruitment, is successful, the secondary results of the trial will be used for planning a confirmative phase III trial. ETHICS AND DISSEMINATION Ethical approval was obtained from the local institutional review board (Ethik-Kommission II at Heidelberg University: 2020-542N). Results will be made publicly available in peer-reviewed scientific journals and presented at appropriate congresses and social media. TRIAL REGISTRATION NUMBER NCT04534998.
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Affiliation(s)
| | | | - Manuel Neuberger
- Department of Urology and Urological Surgery, University Medical Centre Mannheim, Mannheim, Germany
| | - Marietta Kirchner
- Institute of Medical Biometry and Informatics, Heidelberg University, Heidelberg, Germany
| | - Regina Krisam
- Institute of Medical Biometry and Informatics, Heidelberg University, Heidelberg, Germany
| | - Luisa Egen
- Department of Urology and Urological Surgery, University Medical Centre Mannheim, Mannheim, Germany
| | | | - Fabian Siegel
- Department of Urology and Urological Surgery, University Medical Centre Mannheim, Mannheim, Germany
| | - Maurice-Stephan Michel
- Department of Urology and Urological Surgery, University Medical Centre Mannheim, Mannheim, Germany
| | - Patrick Honeck
- Department of Urology and Urological Surgery, University Medical Centre Mannheim, Mannheim, Germany
| | - Philipp Nuhn
- Department of Urology and Urological Surgery, University Medical Centre Mannheim, Mannheim, Germany
| | - Niklas Westhoff
- Department of Urology and Urological Surgery, University Medical Centre Mannheim, Mannheim, Germany
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18
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Nari GA, Gutierrez EC, Layun JL, Falgueras L, Mariot D, Ferret G, Caula C, Góngora J. THERE ARE NO ADVANTAGES BETWEEN LAPAROSCOPIC AND OPEN LIVER RESECTIONS WITHIN AN ENHANCED RECOVERY PROGRAM (ERAS). ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2021; 34:e1593. [PMID: 34669883 PMCID: PMC8521870 DOI: 10.1590/0102-672020210002e1593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 02/23/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND The use of a successful Enhanced Recovery After Surgery (ERAS) in colorectal surgery favored its application in other organs, and hepatic resections were not excluded from this tendency. Some authors suggest that the laparoscopic approach is a central element to obtain better results. AIM To compare the laparoscopic vs. open hepatic resections within an ERAS to evaluate if there are any differences between them. METHODS In a descriptive study 80 hepatic resections that were divided into two groups, regarding to whether they were submitted to laparoscopy or open surgery. Demographic data, those referring to the hepatectomy and the ERAS was analyzed. RESULTS Forty-seven resections were carried out in open surgery and the rest laparoscopically; in the first group there was only one conversion to open surgery. Of the total, 17 resections were major hepatectomies and in 18 simultaneous resections. There were no differences between procedures regarding hospital stay and number of complications. There was a greater adherence to the ERAS (p=0.046) and a faster ambulation (p=0.001) in the open surgery. CONCLUSION The procedure, whether open or laparoscopically done in hepatic resections, does not seem to show differences in an ERAS evaluation.
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Affiliation(s)
| | | | - Jose Luis Layun
- Hospital Transito Caceres de Allende, Cirugía, Córdoba, Argentina
| | - Laia Falgueras
- Servicio de Cirugia Hepatobiliopancreatica, Hospital Josep Trueta, Girona, Espanha
| | - Daniela Mariot
- Hospital Transito Caceres de Allende, Cirugía, Córdoba, Argentina
| | - Georgina Ferret
- Servicio de Cirugia Hepatobiliopancreatica, Hospital Josep Trueta, Girona, Espanha
| | - Celia Caula
- Servicio de Cirugia Hepatobiliopancreatica, Hospital Josep Trueta, Girona, Espanha
| | - Javier Góngora
- Instituto de Salubridad del Estado de Aguascalientes, Estadisticas, Aguascalientes, México
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19
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Maibom SL, Røder MA, Aasvang EK, Rohrsted M, Thind PO, Bagi P, Kistorp T, Poulsen AM, Salling LN, Kehlet H, Brasso K, Joensen UN. Open vs robot-assisted radical cystectomy (BORARC): a double-blinded, randomised feasibility study. BJU Int 2021; 130:102-113. [PMID: 34657367 DOI: 10.1111/bju.15619] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To examine surgical outcomes and feasibility of blinding patients and care providers to the surgical technique of radical cystectomy (RC). PATIENTS AND METHODS Single-centre, parallel-group, double-blinded, randomised feasibility study of open RC (ORC) vs robot-assisted RC with intracorporeal urinary diversion (iRARC) in an 'Enhanced Recovery After Surgery' setup. A total of 50 patients aged ≥18 years with bladder cancer planned for RC with an ileal conduit were included. Patients with previous major abdominal/pelvic surgery, pelvic radiation or anaesthesiological contraindications were excluded. Primary outcomes were proportion of unblinded patients and success of blinding using Bang's Blinding Index. Secondary outcomes included length of stay (LOS), complication rates, blood loss, pain, and opioid consumption. RESULTS A total of 26% of the patients were unblinded before discharge. We demonstrated that patients and doctors remained blinded for the allocated treatment, but nurses did not. Blood loss was greater in the ORC group as was operative time in the iRARC group. We found no difference in complication rate, LOS, or use of analgesics. CONCLUSIONS The present study demonstrates that blinding of surgical technique in RC is possible. The results of secondary outcomes are consistent with the findings of previous unblinded randomised controlled trials. Our study highlights that it is possible to perform a blinded phase III study to explore the optimal surgical technique in RC.
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Affiliation(s)
- Sophia L Maibom
- Urological Research Unit, Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Martin A Røder
- Urological Research Unit, Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Eske K Aasvang
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Anaesthesiology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Malene Rohrsted
- Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Peter O Thind
- Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Per Bagi
- Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Thomas Kistorp
- Department of Anaesthesiology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Alicia M Poulsen
- Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Lisbeth N Salling
- Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Henrik Kehlet
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Section for Surgical Pathophysiology, The Juliane Marie Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Klaus Brasso
- Urological Research Unit, Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ulla N Joensen
- Urological Research Unit, Department of Urology, Centre for Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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20
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Mylius CF, Krijnen WP, Takken T, Lips DJ, Eker H, van der Schans CP, Klaase JM. Objectively measured preoperative physical activity is associated with time to functional recovery after hepato-pancreato-biliary cancer surgery: a pilot study. Perioper Med (Lond) 2021; 10:33. [PMID: 34602089 PMCID: PMC8489102 DOI: 10.1186/s13741-021-00202-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 06/16/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Surgical resection is currently the cornerstone of hepato-pancreato-biliary (HPB) cancer treatment. A low preoperative aerobic fitness level has been identified as a modifiable risk factor associated with complications after major abdominal surgery. A person's aerobic fitness is influenced by performing moderate to vigorous physical activity (MVPA). This study aims to determine the activity monitor measured levels of MVPA performed among patients on the waiting list for HPB cancer surgery and their association with postoperative outcomes. METHODS A prospective, observational multi-center cohort pilot study was conducted. Patients enlisted for resection surgery on suspicion of HPB (pre)malignancy were enrolled. Performed MVPA was measured by an Actigraph wGT3X-BT. Additionally, aerobic fitness was measured via the Incremental Shuttle Walk Test, and (post)operative variables were collected from the electronic patient files. The association between MVPA and the pre- and postoperative variables was determined by univariate and multivariable (logistic) robust regression. RESULTS A total of 38 participants, median age 66.0 (IQR 58.25-74.75) years, were enrolled. The median daily MVPA was 10.7 (IQR 6.9-18.0) min; only 8 participants met the Dutch MVPA guidelines. Participant's age and aerobic fitness were associated with MVPA by multivariable statistical analysis. Time to functional recovery was 8 (IQR 5-12) days and was associated with MVPA and type of surgery (major/minor) in multivariable analysis. CONCLUSION Seventy-six percent of patients enlisted for resection of HPB (pre)malignancy performed insufficient MVPA. A higher level of MVPA was associated with a shorter time to functional recovery.
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Affiliation(s)
- Caspar F Mylius
- Research Group Healthy Ageing, Allied Health Care and Nursing, Hanze University of Applied Sciences, Petrus Driessenstraat 3, 9714 CA, Groningen, The Netherlands.
| | - Wim P Krijnen
- Research Group Healthy Ageing, Allied Health Care and Nursing, Hanze University of Applied Sciences, Petrus Driessenstraat 3, 9714 CA, Groningen, The Netherlands
| | - Tim Takken
- Child Development and Exercise Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Daan J Lips
- Department of Surgery, Medical Spectrum Twente, Enschede, The Netherlands
| | - Hasan Eker
- Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Cees P van der Schans
- Research Group Healthy Ageing, Allied Health Care and Nursing, Hanze University of Applied Sciences, Petrus Driessenstraat 3, 9714 CA, Groningen, The Netherlands.,Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Health Psychology Research, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Joost M Klaase
- Department of Hepatobiliary Surgery and Liver Transplantation, University Medical Centre Groningen, Groningen, The Netherlands
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21
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Kamarajah SK, Gujjuri RR, Hilal MA, Manas DM, White SA. Does minimally invasive liver resection improve long-term survival compared to open resection for hepatocellular carcinoma? A systematic review and meta-analysis. Scand J Surg 2021; 111:14574969211042455. [PMID: 34605328 DOI: 10.1177/14574969211042455] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Minimally invasive liver surgery for hepatocellular carcinoma has gained widespread interest as an alternative to conventional open liver surgery. However, long-term survival benefits of this approach seem unclear. This meta-analysis was conducted to investigate long-term survival following minimally invasive liver surgery. METHOD A systematic review was performed to identify studies comparing long-term survival after minimally invasive liver surgery and open liver surgery until January 2020. The I2 test was used to test for statistical heterogeneity and publication bias was assessed using Egger test. Random-effects meta-analysis was performed for all-cause 5-year (main outcome) and 3-year mortality, and disease-specific 5-year and 3-year mortality. Meta-regression was performed for the 5-year and 3-year survival outcomes with adjustment for study factors (region, design), annual center volume, patient factors (American Society of Anesthesiologists (ASA) grade, gender, age, body mass index, cirrhosis, tumor size, and number), and resection extent. Sensitivity analyses were performed on studies by study year, region, annual center volume, and resection type. RESULT The review identified 50 relevant studies including 13,731 patients undergoing liver resection for hepatocellular carcinoma of which 4071 (25.8%) underwent minimally invasive liver surgery. Pooled analysis revealed similar all-cause (odds ratio: 0.83, 95% confidence interval: 0.70-1.11, p = 0.3) and disease-specific (odds ratio: 0.93, 95% confidence interval: 0.80-1.09, p = 0.4) 5-year mortality after minimally invasive liver surgery compared with open liver surgery. Sensitivity analysis of published studies from 2010 to 2019 demonstrated a significantly lower disease-specific 3-year mortality (odds ratio: 0.75, 95% confidence interval: 0.59-0.96, p = 0.022) and all-cause 5-year mortality (odds ratio: 0.63, 95% confidence interval: 0.50-0.81, p = 0.002). Meta-regression identified no confounding factors in all analyses. CONCLUSIONS Improvement in minimally invasive liver surgery techniques over the past decade appears to demonstrate superior disease-specific mortality with minimally invasive liver surgery compared to open liver surgery. Therefore, minimally invasive liver surgery can be recommended as an alternative surgical approach for hepatocellular carcinoma.
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Affiliation(s)
- Sivesh K Kamarajah
- BMedSci, MBChB Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle University NHS Trust Hospitals, NE7 7DN, Newcastle upon Tyne, UK Institute of Cellular Medicine, Newcastle University, NE2 4HH, Newcastle upon Tyne, UK
| | - Rohan R Gujjuri
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Moh'd A Hilal
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK
| | - Derek M Manas
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle University NHS Trust Hospitals, Newcastle upon Tyne, UK; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Steven A White
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle University NHS Trust Hospitals, Newcastle upon Tyne, UK; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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22
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Haney CM, Studier-Fischer A, Probst P, Fan C, Müller PC, Golriz M, Diener MK, Hackert T, Müller-Stich BP, Mehrabi A, Nickel F. A systematic review and meta-analysis of randomized controlled trials comparing laparoscopic and open liver resection. HPB (Oxford) 2021; 23:1467-1481. [PMID: 33820689 DOI: 10.1016/j.hpb.2021.03.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/04/2021] [Accepted: 03/05/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND/PURPOSE The dissemination of laparoscopic liver resection (LLR) has been based on non-randomized studies and reviews of these. Aim of this study was to evaluate if the randomized evidence comparing LLR to open liver resection (OLR) supports these findings. METHODS A prospectively registered (reviewregistry866) systematic review and meta-analysis following Cochrane and PRISMA guidelines comparing LLR to OLR for benign and malignant diseases was performed via Medline, Web of Science, CENTRAL up to 31.12.2020. The main outcome was postoperative complications. Risk of bias was assessed with the Cochrane Risk of Bias tool 2.0, certainty of evidence was assessed using the GRADE approach. RESULTS The search yielded 2080 results. 13 RCTs assessing mostly minor liver resections with 1457 patients were included. There were reduced odds of experiencing any complication (Odds ratio (OR) [95% confidence interval (CI)]: 0·42 [0·30, 0·58]) and severe complications (OR[CI]: 0·51 [0·31, 0·84]) for patients undergoing LLR. LOS was shorter (Mean difference (MD) [CI]: -2·90 [-3·88, -1·92] days), blood loss was lower (MD: [CI]: -115·41 [-146·08, -84·75] ml), and functional recovery was better for LLR. All other outcomes showed no significant differences. CONCLUSIONS LLR shows significant postoperative benefits. RCTs assessing long-term outcomes and major resections are needed.
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Affiliation(s)
- Caelán M Haney
- Department of General, Visceral, and Transplantation Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - Alexander Studier-Fischer
- Department of General, Visceral, and Transplantation Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral, and Transplantation Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany; Study Center of the German Surgical Society, Im Neuenheimer Feld 130, 69120 Heidelberg, Germany
| | - Carolyn Fan
- Department of General, Visceral, and Transplantation Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - Philip C Müller
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Mohammad Golriz
- Department of General, Visceral, and Transplantation Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral, and Transplantation Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - Beat P Müller-Stich
- Department of General, Visceral, and Transplantation Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - Felix Nickel
- Department of General, Visceral, and Transplantation Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany.
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23
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van Hilst J, Korrel M, Lof S, de Rooij T, Vissers F, Al-Sarireh B, Alseidi A, Bateman AC, Björnsson B, Boggi U, Bratlie SO, Busch O, Butturini G, Casadei R, Dijk F, Dokmak S, Edwin B, van Eijck C, Esposito A, Fabre JM, Falconi M, Ferrari G, Fuks D, Groot Koerkamp B, Hackert T, Keck T, Khatkov I, de Kleine R, Kokkola A, Kooby DA, Lips D, Luyer M, Marudanayagam R, Menon K, Molenaar Q, de Pastena M, Pietrabissa A, Rajak R, Rosso E, Sanchez Velazquez P, Saint Marc O, Shah M, Soonawalla Z, Tomazic A, Verbeke C, Verheij J, White S, Wilmink HW, Zerbi A, Dijkgraaf MG, Besselink MG, Abu Hilal M. Minimally invasive versus open distal pancreatectomy for pancreatic ductal adenocarcinoma (DIPLOMA): study protocol for a randomized controlled trial. Trials 2021; 22:608. [PMID: 34503548 PMCID: PMC8427847 DOI: 10.1186/s13063-021-05506-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 08/03/2021] [Indexed: 01/08/2023] Open
Abstract
Background Recently, the first randomized trials comparing minimally invasive distal pancreatectomy (MIDP) with open distal pancreatectomy (ODP) for non-malignant and malignant disease showed a 2-day reduction in time to functional recovery after MIDP. However, for pancreatic ductal adenocarcinoma (PDAC), concerns have been raised regarding the oncologic safety (i.e., radical resection, lymph node retrieval, and survival) of MIDP, as compared to ODP. Therefore, a randomized controlled trial comparing MIDP and ODP in PDAC regarding oncological safety is warranted. We hypothesize that the microscopically radical resection (R0) rate is non-inferior for MIDP, as compared to ODP. Methods/design DIPLOMA is an international randomized controlled, patient- and pathologist-blinded, non-inferiority trial performed in 38 pancreatic centers in Europe and the USA. A total of 258 patients with an indication for elective distal pancreatectomy with splenectomy because of proven or highly suspected PDAC of the pancreatic body or tail will be randomly allocated to MIDP (laparoscopic or robot-assisted) or ODP in a 1:1 ratio. The primary outcome is the microscopically radical resection margin (R0, distance tumor to pancreatic transection and posterior margin ≥ 1 mm), which is assessed using a standardized histopathology assessment protocol. The sample size is calculated with the following assumptions: 5% one-sided significance level (α), 80% power (1-β), expected R0 rate in the open group of 58%, expected R0 resection rate in the minimally invasive group of 67%, and a non-inferiority margin of 7%. Secondary outcomes include time to functional recovery, operative outcomes (e.g., blood loss, operative time, and conversion to open surgery), other histopathology findings (e.g., lymph node retrieval, perineural- and lymphovascular invasion), postoperative outcomes (e.g., clinically relevant complications, hospital stay, and administration of adjuvant treatment), time and site of disease recurrence, survival, quality of life, and costs. Follow-up will be performed at the outpatient clinic after 6, 12, 18, 24, and 36 months postoperatively. Discussion The DIPLOMA trial is designed to investigate the non-inferiority of MIDP versus ODP regarding the microscopically radical resection rate of PDAC in an international setting. Trial registration ISRCTN registry ISRCTN44897265. Prospectively registered on 16 April 2018.
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Affiliation(s)
- Jony van Hilst
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | - Maarten Korrel
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | - Sanne Lof
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands.,Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Thijs de Rooij
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | - Frederique Vissers
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | | | - Adnan Alseidi
- Department of Surgery, Virginia Mason Medical Center, Seattle, USA
| | - Adrian C Bateman
- Department of Cellular Pathology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Bergthor Björnsson
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Ugo Boggi
- Department of Surgery, Universitá di Pisa, Pisa, Italy
| | - Svein Olav Bratlie
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Olivier Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands
| | | | - Riccardo Casadei
- Division of Pancreatic Surgery IRCCS, Azienda Ospedaliero Universitaria Department of Internal Medicine and Surgery (DIMEC), S. Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Frederike Dijk
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Safi Dokmak
- Department of HPB surgery and liver transplantation, Beaujon Hospital, Clichy, France
| | - Bjorn Edwin
- Department of Surgery, Oslo University Hospital and Institute for Clinical Medicine, Oslo, Norway
| | - Casper van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Alessandro Esposito
- Department of General and Pancreatic Surgery - Pancreas Institute, University Hospital of Verona, Verona, Italy
| | | | - Massimo Falconi
- Department of Surgery, San Raffaele Hospital IRCCS, Università Vita-Salute, Milan, Italy
| | - Giovanni Ferrari
- Department of Surgery, Niguarda Ca'Granda Hospital, Milan, Italy
| | - David Fuks
- Department of Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Thilo Hackert
- Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Tobias Keck
- Department of Surgery, UKSH campus Lübeck, Lübeck, Germany
| | - Igor Khatkov
- Department of Surgery, Moscow Clinical Scientific Center, Moscow, Russian Federation
| | - Ruben de Kleine
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Arto Kokkola
- Department of Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - David A Kooby
- Department of Surgery, Emory University Hospital, Atlanta, USA
| | - Daan Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Misha Luyer
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, the Netherlands
| | - Ravi Marudanayagam
- Department of HPB Surgery, University Hospital Birmingham, Birmingham, UK
| | - Krishna Menon
- Department of Surgery, King's College Hospital NHS Foundation Trust, London, UK
| | - Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Matteo de Pastena
- Department of General and Pancreatic Surgery - Pancreas Institute, University Hospital of Verona, Verona, Italy
| | | | - Rushda Rajak
- Department of Surgery, Virginia Mason Medical Center, Seattle, USA
| | - Edoardo Rosso
- Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | | | - Olivier Saint Marc
- Department of Surgery, Centre Hospitalier Regional D'Orleans, Orleans, France
| | - Mihir Shah
- Department of Surgery, Emory University Hospital, Atlanta, USA
| | - Zahir Soonawalla
- Department of Surgery, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Ales Tomazic
- Department of Surgery, University Medical Center Ljubljana, Ljubljana, Slovenia
| | | | - Joanne Verheij
- Department of Pathology, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Steven White
- Department of Surgery, The Freeman Hospital Newcastle Upon Tyne, Newcastle, UK
| | - Hanneke W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Alessandro Zerbi
- Department of Surgery, Humanitas Clinical and Research Center-IRCCS, Rozzano (MI) and Humanitas University, Pieve Emanuele, MI, Italy
| | - Marcel G Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, VUMC, ZH-7F18, PO Box 7057, 1007 MB, Amsterdam, the Netherlands.
| | - Mohammad Abu Hilal
- Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy. .,Department of General Surgery, Fondazione Poliambulanza Instituto Ospedaliero, Brescia, Italy.
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24
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Nösser M, Feldbrügge L, Pratschke J. Minimally invasive liver surgery: the Charité experience. Turk J Surg 2021; 37:199-206. [DOI: 10.47717/turkjsurg.2021.1011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 08/12/2021] [Indexed: 12/12/2022]
Abstract
Minimally invasive liver surgery (MILS) was established as last abdominal surgical specialty through the 1990s. With a shift from mainly benign to malignant indications, MILS was shown to be equal to open liver surgery in terms of oncological outcomes, with benefits in intraoperative blood loss, postoperative pain, postoperative complication rates, hospital length of stay and quality of life. With colorectal liver metastases and hepatocellular carcinoma as the most common indications, most liver resection can be performed minimally invasive nowadays, including patients with liver cirrhosis. Initially perceived limitations of laparoscopic liver surgery were weakened by gaining experience, technical progress and pioneering of new resection approaches. Lately robotic liver surgery was adopted to the field of MILS to further push the limits. To simplify first resections, technical variations of the minimally invasive approach can be utilized, and difficulty scores help to select resections suitable to the level of experience. We hereby give an overview of the establishing of a minimally invasive liver surgery program at our center.
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25
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Zhang G, Pan B, Tan D, Ling Y. Risk factors of delayed recovery from general anesthesia in patients undergoing radical biliary surgery: What can we prevent. Medicine (Baltimore) 2021; 100:e26773. [PMID: 34397880 PMCID: PMC8360616 DOI: 10.1097/md.0000000000026773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 07/02/2021] [Indexed: 01/04/2023] Open
Abstract
Delayed recovery (DR) is very commonly seen in the patients undergoing laparoscopic radical biliary surgery, we aimed to investigate the potential risk factors of DR in the patients undergoing radical biliary surgery, to provide evidences into the management of DR.Patients who underwent radical biliary surgery from January 1, 2018 to August 31, 2020 were identified. The clinical characteristics and treatment details of DR and no-DR patients were compared and analyzed. Multivariable logistic regression analyses were conducted to identify the potential influencing factors for DR in patients with laparoscopic radical biliary surgery.We included a total of 168 patients with laparoscopic radical biliary surgery, the incidence of postoperative DR was 25%. There were significant differences on the duration of surgery, duration of anesthesia, and use of intraoperative combined sevoflurane inhalation (all P < .05), and there were not significant differences on American Society of Anesthesiologists, New York Heart Association, tumor-lymph node- metastasis, and estimated blood loss between DR group and control group (all P > .05). Multivariable logistic regression analyses indicated that age ≥70 years (odd ratio [OR] 1.454, 95% confidence interval [CI] 1.146-1.904), body mass index ≥25 kg/m2 (OR 1.303, 95% CI 1.102-1.912), alcohol drinking (OR 2.041, 95% CI 1.336-3.085), smoking (OR 1.128, 95% CI 1.007-2.261), duration of surgery ≥220 minutes (OR 1.239, 95% CI 1.039-1.735), duration of anesthesia ≥230 minutes (OR 1.223, 95% CI 1.013-1.926), intraoperative combined sevoflurane inhalation (OR 1.207, 95% CI 1.008-1.764) were the independent risk factors for DR in patients with radical biliary surgery (all P < .05).It is clinically necessary to take early countermeasures against various risk factors to reduce the occurrence of DR, and to improve the prognosis of patients.
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26
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Onda S, Furukawa K, Haruki K, Yasuda J, Shirai Y, Hamura R, Shiozaki H, Gocho T, Shiba H, Ikegami T. Proposal for a revised system for classifying difficulty of laparoscopic partial liver resection. Langenbecks Arch Surg 2021; 406:1533-1541. [PMID: 34165596 DOI: 10.1007/s00423-021-02253-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 06/17/2021] [Indexed: 01/22/2023]
Abstract
PURPOSE The aim of this retrospective study was to evaluate a revised classification system for predicting the difficulty of laparoscopic partial liver resection. METHODS Patients who had undergone initial laparoscopic partial liver resection for a solitary lesion from January 2012 to February 2021were classified into two groups according to the type of procedure performed, "scooping-out" versus "cutting." The participants were then further divided into "small" and "large" subgroups according to the tumor's depth and diameter. Finally, they were categorized into two groups, namely "standard" and "advanced." Operative outcomes were compared between the two groups and the proposed revised system for classifying difficulty of laparoscopic partial liver resection compared with the existing scoring system. RESULTS Of the 65 procedures assessed, 40 were categorized as standard and 25 as advanced. Tumor size (P < 0.001), operation time (P < 0.001), volume of intraoperative blood loss (P = 0.001), rate of the Pringle maneuver (P = 0.044), and resected liver weight (P < 0.001) were significantly greater in the advanced than in the standard group. Differences in operation time and intraoperative blood loss were not identified by the existing difficulty scoring system. CONCLUSION The proposed revised classification is useful for predicting the difficulty of laparoscopic partial liver resection.
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Affiliation(s)
- Shinji Onda
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Kenei Furukawa
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Koichiro Haruki
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Jungo Yasuda
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yoshihiro Shirai
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Ryoga Hamura
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Hironori Shiozaki
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Takeshi Gocho
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Hioaki Shiba
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Toru Ikegami
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 105-8461, Japan
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International multicenter propensity score matched study on laparoscopic versus open left lateral sectionectomy. HPB (Oxford) 2021; 23:707-714. [PMID: 33039275 DOI: 10.1016/j.hpb.2020.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 07/07/2020] [Accepted: 09/07/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Despite a lack of high-level evidence, current guidelines recommend laparoscopic left lateral sectionectomy (LLLS) as the routine approach over open LLS (OLLS). Randomized studies and propensity score matched studies on LLLS vs OLLS for all indications, including malignancy, are lacking. METHODS This international multicenter propensity score matched retrospective cohort study included consecutive patients undergoing LLLS or OLLS in six centers from three European countries (January 2000-December 2016). Propensity scores were calculated based on nine preoperative variables and LLLS and OLLS were matched in a 1:1 ratio. Short-term operative outcomes were compared using paired tests. RESULTS A total of 560 patients were included. Out of 200 LLLS, 139 could be matched to 139 OLLS. After matching, baseline characteristics were well balanced. LLLS was associated with shorter operative time (144 (110-200) vs 199 (138-283) minutes, P < 0.001), less blood loss (100 (50-300) vs 350 (100-750) mL, P = 0.005) and a 3-day shorter postoperative hospital stay (4 (3-7) vs 7 (5-9) days, P < 0.001). CONCLUSION This international multicenter propensity score matched study confirms the superiority of LLLS over OLLS based on shorter postoperative hospital stay, operative time, and less blood loss thus validating current guideline advice.
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Zou J, Li S, Wang Q, Mei J, Lu L, Lin W, Wen Y, Li Y, Wei W, Guo R. Surgical strategies for hepatocellular carcinoma located in the left lateral lobe: A propensity score-matched and prognostic nomogram study. Cancer Med 2021; 10:3274-3287. [PMID: 33932132 PMCID: PMC8124126 DOI: 10.1002/cam4.3894] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 03/09/2021] [Accepted: 03/21/2021] [Indexed: 12/24/2022] Open
Abstract
PURPOSE For hepatocellular carcinoma (HCC) located in the left lateral lobe, the optimal surgical procedure is still controversial. This study aimed to optimize surgical strategies and to construct a nomogram to predict the postoperative survival of patients with HCC. METHODS Between 1 January 2005 and 30 September 2018, a total of 493 patients were enrolled. Propensity score matching (PSM) was performed between the left lateral lobectomy (LLL) and left hepatectomy (LH) groups (1:1). The study endpoints were overall survival (OS), recurrence-free survival (RFS), and safety. A nomogram was generated using a multivariate Cox proportional hazards model. The discriminative ability and calibration of the nomogram were evaluated using C-statistics and calibration plots. RESULTS After matching, 87 pairs were included. The LH group had better 1-, 3-, and 5-year OS rates than the LLL group (88%, 73%, and 69% vs. 73%, 57%, and 49%, respectively; p = 0.017). The 1-, 3-, and 5-year RFS rates of the LH group were similar to those of the LLL group (64%, 49%, and 46% vs. 63%, 51%, and 42%, respectively; p = 0.652). There were no significant differences in postoperative complications. Eight factors were integrated into the nomogram and it had good discriminative ability and calibration. CONCLUSION Our data revealed that compared to LLL, LH may result in better OS and have similar postoperative complications for HCC. The nomogram may serve as a practical tool for the individual prognostic evaluation of patients with HCC.
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Affiliation(s)
- Jingwen Zou
- Department of Liver SurgerySun Yat‐sen University Cancer CenterGuangzhouP. R. China
- State Key Laboratory of Oncology in South ChinaCollaborative Innovation Center for Cancer MedicineGuangzhouP. R. China
| | - Shaohua Li
- Department of Liver SurgerySun Yat‐sen University Cancer CenterGuangzhouP. R. China
- State Key Laboratory of Oncology in South ChinaCollaborative Innovation Center for Cancer MedicineGuangzhouP. R. China
| | - Qiaoxuan Wang
- State Key Laboratory of Oncology in South ChinaCollaborative Innovation Center for Cancer MedicineGuangzhouP. R. China
- Department of Radiation OncologySun Yat‐sen University Cancer CenterGuangzhouP. R. China
| | - Jie Mei
- Department of Liver SurgerySun Yat‐sen University Cancer CenterGuangzhouP. R. China
- State Key Laboratory of Oncology in South ChinaCollaborative Innovation Center for Cancer MedicineGuangzhouP. R. China
| | - Lianghe Lu
- Department of Liver SurgerySun Yat‐sen University Cancer CenterGuangzhouP. R. China
- State Key Laboratory of Oncology in South ChinaCollaborative Innovation Center for Cancer MedicineGuangzhouP. R. China
| | - Wenping Lin
- Department of Liver SurgerySun Yat‐sen University Cancer CenterGuangzhouP. R. China
- State Key Laboratory of Oncology in South ChinaCollaborative Innovation Center for Cancer MedicineGuangzhouP. R. China
| | - Yuhua Wen
- Department of Liver SurgerySun Yat‐sen University Cancer CenterGuangzhouP. R. China
- State Key Laboratory of Oncology in South ChinaCollaborative Innovation Center for Cancer MedicineGuangzhouP. R. China
| | - Yuechao Li
- Department of Liver SurgerySun Yat‐sen University Cancer CenterGuangzhouP. R. China
- State Key Laboratory of Oncology in South ChinaCollaborative Innovation Center for Cancer MedicineGuangzhouP. R. China
| | - Wei Wei
- Department of Liver SurgerySun Yat‐sen University Cancer CenterGuangzhouP. R. China
- State Key Laboratory of Oncology in South ChinaCollaborative Innovation Center for Cancer MedicineGuangzhouP. R. China
| | - Rongping Guo
- Department of Liver SurgerySun Yat‐sen University Cancer CenterGuangzhouP. R. China
- State Key Laboratory of Oncology in South ChinaCollaborative Innovation Center for Cancer MedicineGuangzhouP. R. China
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Wei D, Johnston S, Patkar A, Buell JF. Comparison of clinical and economic outcomes between minimally invasive liver resection and open liver resection: a propensity-score matched analysis. HPB (Oxford) 2021; 23:785-794. [PMID: 33046367 DOI: 10.1016/j.hpb.2020.09.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 09/15/2020] [Accepted: 09/21/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Minimally invasive liver resection (MILR) has gained momentum in recent years. This study of contemporary data compares economic and clinical outcomes between MILR and open liver resection (OLR). METHODS We extracted data for patients undergoing liver resection between October 2015-September 2018 from the Premier Healthcare Database. We conducted a propensity score matched analysis to compare complications, in-hospital mortality, inpatient readmissions, discharge to institutional post-acute care, operating room time (ORT), length of stay (LOS), and total hospital cost between MILR and OLR patients. RESULTS From the eligible OLR (n = 3349) and MILR (n = 1367) patients, we propensity score matched 1261 from each cohort at a 1:1 ratio. After matching, MILR was associated with lower rates of complications (bleeding: 8.2% vs. 17.4%; respiratory failure: 5.5% vs. 10.9%; intestinal obstruction: 3.6% vs. 6.0%, and pleural effusion: 1.9% vs. 4.9%), in-hospital mortality (0.5% vs. 3.0%), 90-day inpatient readmissions (10.4% vs. 14.3%), discharge to institutional post-acute care (6.9% vs. 12.3%), shorter ORT (257 vs. 308 min) and LOS (4.3 vs. 7.2 days), and lower hospital costs ($19463 vs. $29119) (all P < 0.001). CONCLUSION MILR was associated with lower risk of complications and reduced hospital resource utilizations as compared with OLR.
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Affiliation(s)
- David Wei
- Epidemiology, Medical Devices, Johnson and Johnson, New Brunswick, NJ, USA
| | - Stephen Johnston
- Epidemiology, Medical Devices, Johnson and Johnson, New Brunswick, NJ, USA.
| | - Anuprita Patkar
- Global Health Economics and Market Access, Ethicon, Somerville, NJ, USA
| | - Joseph F Buell
- Mission Health System, HCA North Carolina, Asheville, NC, USA
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Wang JM, Li JF, Yuan GD, He SQ. Robot-assisted versus laparoscopic minor hepatectomy: A systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e25648. [PMID: 33907124 PMCID: PMC8084038 DOI: 10.1097/md.0000000000025648] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 02/14/2021] [Accepted: 03/17/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Robot-assisted and laparoscopic surgery are the most minimally invasive surgical approaches for the removal of liver lesions. Minor hepatectomy is a common surgical procedure. In this study, we evaluated the advantages and disadvantages of robot-assisted vs laparoscopic minor hepatectomy (LMH). METHODS A systematic literature search was performed in PubMed, Embase, and the Cochrane Library to identify comparative studies on robot-assisted vs. laparoscopicminor hepatectomy up to February, 2020. The odds ratios (OR) and mean differences with 95% confidence intervals were calculated using the fixed-effects model or random-effects model. RESULTS A total of 12 studies involving 751 patients were included in the meta-analysis. Among them, 297 patients were in the robot-assisted minor hepatectomy (RMH) group and 454 patients were in the LMH group. There were no significant differences in intraoperative blood loss (P = .43), transfusion rates (P = .14), length of hospital stay (P > .64), conversion rate (P = .62), R0 resection rate (P = .56), complications (P = .92), or mortaliy (P = .37) between the 2 groups. However, the RMH group was associated with a longer operative time (P = .0003), and higher cost (P < .00001) compared to the LMH group. No significant differences in overall survival or disease free survival between the 2 groups were observed. In the subgroup analysis of left lateral sectionectomies, RMH was still associated with a longer operative time, but no other differences in clinical outcomes were observed. CONCLUSIONS Although RMH is associated with longer operation times and higher costs, it exhibits the same safety and effectiveness as LMH. Prospective randomized controlled clinical trials should now be considered to obtain better evidence for clinical consensus.
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31
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Kang T, Jia Z, Xing G, Zhou Q. Comparison of Clinical Outcomes Between Chinese Patients Receiving Hepatectomy With or Without Enhanced Recovery After Surgery Strategy. Front Surg 2021; 8:645935. [PMID: 33842531 PMCID: PMC8033151 DOI: 10.3389/fsurg.2021.645935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 02/16/2021] [Indexed: 11/13/2022] Open
Abstract
Purposes: For the first time in China, the current study was designed to compare the clinical outcomes between Chinese patients receiving hepatectomy with or without the enhanced recovery after surgery (ERAS) strategy. Methods: The current study enrolled 250 patients who would receive hepatectomy. Patients were randomized into two groups: ERAS group (n = 125, ERAS strategy) and control (n = 125, conventional care). Mortality, length of hospital stay, readmission, and complications were assessed over 30 days after the operation. Results: The average age of the whole cohort was 65 (63-68) years, with 152 males (60.8%). There was no difference between two groups in baseline features, such as age, sex, medical history, Child-Pugh hepatic function, American Society of Anaesthesiologists physical status, operative type, hepatectomy type, and hepatic pathology (P > 0.05 for all). There was no occurrence of death in the two groups. Patients in the ERAS group had significantly less occurrence of post-operative complications and a shorter length of hospital stay (P < 0.05 for all). Deep vein thrombosis occurred in seven patients in the control group, but did not occur in the ERAS group (P < 0.05). Patients in the two groups had similar occurrence of readmission (P > 0.05). Conclusions: ERAS strategy significantly decreased the occurrence of operative complications and shortened the length of hospital stay without any increase in mortality or readmission in Chinese patients receiving hepatectomy.
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Affiliation(s)
- Tieli Kang
- Department of Hepatobiliary Surgery, Inner Mongolia Xing'an Meng People's Hospital, Ulanhot, China
| | - Zhishuo Jia
- Department of Hepatobiliary Surgery, Inner Mongolia Xing'an Meng People's Hospital, Ulanhot, China
| | - Guoquan Xing
- Department of Hepatobiliary Surgery, Inner Mongolia Xing'an Meng People's Hospital, Ulanhot, China
| | - Quanhe Zhou
- Department of Hepatobiliary Surgery, Inner Mongolia Xing'an Meng People's Hospital, Ulanhot, China
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Chiow AKH, Rho SY, Wee IJY, Lee LS, Choi GH. Robotic ICG guided anatomical liver resection in a multi-centre cohort: an evolution from "positive staining" into "negative staining" method. HPB (Oxford) 2021; 23:475-482. [PMID: 32863114 DOI: 10.1016/j.hpb.2020.08.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 07/16/2020] [Accepted: 08/06/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Laparoscopic major anatomical liver resection is challenging. The robotic liver resection (RLR) approach, with Firefly indocyanine green (ICG) imaging, was proposed to overcome the limitations of laparoscopy. The aim of this multi-centre international study was to evaluate the use of Firefly ICG imaging in anatomical RLR. METHODS A retrospective study of consecutive patients undergoing RLR anatomical resection with intra-operative ICG administration from January 2015 to July 2018 were enrolled. Patients who underwent simultaneous or en-bloc resections of other organs were excluded. RESULTS A total of 52 patients were recruited of which 32 patients were healthy donors, 17 with malignancy and 3 for benign conditions. 12 patients had cirrhosis. 28 patients underwent a right hepatectomy (53.8%) with left hepatectomy performed with 18 patients. 40 patients underwent negative staining and 12 patients via direct portal vein injection for positive staining. ICG demarcation line was visualized in 43 patients and was clearer than the ischaemic demarcation line in 29 patients. All resections for malignancy had clear margins. There were no 30-day/inpatient mortalities. CONCLUSION Robotic ICG guided hepatectomy technique for anatomical liver resection is safe, feasible and has the benefit for improved visualization in healthy donors and cirrhotic patients.
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Affiliation(s)
- Adrian K H Chiow
- Hepatopancreatobiliary Unit, Department of Surgery, Changi General Hospital, Singapore
| | - Seoung Yoon Rho
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ian J Y Wee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lip Seng Lee
- Hepatopancreatobiliary Unit, Department of Surgery, Changi General Hospital, Singapore.
| | - Gi Hong Choi
- Division of Hepatopancreatobiliary Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Wakabayashi T, Benedetti Cacciaguerra A, Ciria R, Ariizumi S, Durán M, Golse N, Ogiso S, Abe Y, Aoki T, Hatano E, Itano O, Sakamoto Y, Yoshizumi T, Yamamoto M, Wakabayashi G. Landmarks to identify segmental borders of the liver: A review prepared for PAM-HBP expert consensus meeting 2021. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 29:82-98. [PMID: 33484112 DOI: 10.1002/jhbp.899] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/11/2021] [Accepted: 01/19/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND In preparation for the upcoming consensus meeting in Tokyo in 2021, this systematic review aimed to analyze the current available evidence regarding surgical anatomy of the liver, focusing on useful landmarks, strategies and technical tools to perform precise anatomic liver resection (ALR). METHODS A systematic review was conducted on MEDLINE/PubMed for English articles and on Ichushi database for Japanese articles until September 2020. The quality assessment of the articles was performed in accordance with the Scottish Intercollegiate Guidelines Network (SIGN). RESULTS A total of 3169 manuscripts were obtained, 1993 in English and 1176 in Japanese literature. Subsequently, 63 English and 20 Japanese articles were selected and reviewed. The quality assessment of comparative series and case series was revealed to be usually low; only six articles were qualified as high quality. Forty-two articles focused on analyzing intersegmental/sectional planes and their relationship with specific hepatic landmark veins. In 12 articles, the authors aimed to investigate liver surface anatomic structures, while 36 articles aimed to study technological tools and contrast agents for surgical segmentation during ALR. Although Couinaud's classification has remained the cornerstone in daily diagnostic/surgical practices, it does not always portray the realistic liver segmentation and there has been no standardization on which a single strategy should be followed to perform precise ALR. CONCLUSIONS A global consensus should be pursued in order to establish clear guidelines and proper recommendations to perform ALR in the era of minimally invasive surgery.
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Affiliation(s)
- Taiga Wakabayashi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Andrea Benedetti Cacciaguerra
- Department of Surgery, Hepato-Pancreato-Biliary, Minimally Invasive and Robotic Unit, Istituto Fondazione Poliambulanza, Brescia, Italy
| | - Ruben Ciria
- Unit of Hepatobiliary Surgery and Liver Transplantation, University Hospital Reina Sofía, IMIBIC, Cordoba, Spain
| | - Shunichi Ariizumi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Manuel Durán
- Unit of Hepatobiliary Surgery and Liver Transplantation, University Hospital Reina Sofía, IMIBIC, Cordoba, Spain
| | - Nicolas Golse
- Hepatobiliary Center, Paul Brousse Hospital, Villejuif, France
| | - Satoshi Ogiso
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yuta Abe
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Takeshi Aoki
- Department of Gastroenterological and General Surgery, School of Medicine, Showa University, Tokyo, Japan
| | - Etsuro Hatano
- Department of Gastroenterological Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Osamu Itano
- Department of Hepato-Biliary-Pancreatic and Gastrointestinal Surgery, International University of Health and Welfare School of Medicine, Chiba, Japan
| | - Yoshihiro Sakamoto
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Tokyo, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Go Wakabayashi
- Center for Advanced Treatment of Hepatobiliary and Pancreatic Diseases, Ageo Central General Hospital, Saitama, Japan
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Minimal-Invasive Versus Open Hepatectomy for Colorectal Liver Metastases: Bicentric Analysis of Postoperative Outcomes and Long-Term Survival Using Propensity Score Matching Analysis. J Clin Med 2020; 9:jcm9124027. [PMID: 33322087 PMCID: PMC7764401 DOI: 10.3390/jcm9124027] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/02/2020] [Accepted: 12/09/2020] [Indexed: 12/14/2022] Open
Abstract
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.
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Martin J, Petrillo A, Smyth EC, Shaida N, Khwaja S, Cheow HK, Duckworth A, Heister P, Praseedom R, Jah A, Balakrishnan A, Harper S, Liau S, Kosmoliaptsis V, Huguet E. Colorectal liver metastases: Current management and future perspectives. World J Clin Oncol 2020; 11:761-808. [PMID: 33200074 PMCID: PMC7643190 DOI: 10.5306/wjco.v11.i10.761] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/14/2020] [Accepted: 08/31/2020] [Indexed: 02/06/2023] Open
Abstract
The liver is the commonest site of metastatic disease for patients with colorectal cancer, with at least 25% developing colorectal liver metastases (CRLM) during the course of their illness. The management of CRLM has evolved into a complex field requiring input from experienced members of a multi-disciplinary team involving radiology (cross sectional, nuclear medicine and interventional), Oncology, Liver surgery, Colorectal surgery, and Histopathology. Patient management is based on assessment of sophisticated clinical, radiological and biomarker information. Despite incomplete evidence in this very heterogeneous patient group, maximising resection of CRLM using all available techniques remains a key objective and provides the best chance of long-term survival and cure. To this end, liver resection is maximised by the use of downsizing chemotherapy, optimisation of liver remnant by portal vein embolization, associating liver partition and portal vein ligation for staged hepatectomy, and combining resection with ablation, in the context of improvements in the functional assessment of the future remnant liver. Liver resection may safely be carried out laparoscopically or open, and synchronously with, or before, colorectal surgery in selected patients. For unresectable patients, treatment options including systemic chemotherapy, targeted biological agents, intra-arterial infusion or bead delivered chemotherapy, tumour ablation, stereotactic radiotherapy, and selective internal radiotherapy contribute to improve survival and may convert initially unresectable patients to operability. Currently evolving areas include biomarker characterisation of tumours, the development of novel systemic agents targeting specific oncogenic pathways, and the potential re-emergence of radical surgical options such as liver transplantation.
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Affiliation(s)
- Jack Martin
- Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Angelica Petrillo
- Department of Precision Medicine, Division of Medical Oncology, University of Campania "L. Vanvitelli", Napoli 80131, Italy, & Medical Oncology Unit, Ospedale del Mare, 80147 Napoli Italy
| | - Elizabeth C Smyth
- Department of Oncology, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Nadeem Shaida
- Department of Radiology, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB22 0QQ, United Kingdom
| | - Samir Khwaja
- Department of Radiology, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB22 0QQ, United Kingdom
| | - HK Cheow
- Department of Nuclear Medicine, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Adam Duckworth
- Department of Pathology, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Paula Heister
- Department of Pathology, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Raaj Praseedom
- Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Asif Jah
- Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Anita Balakrishnan
- Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Simon Harper
- Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Siong Liau
- Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Vasilis Kosmoliaptsis
- Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
| | - Emmanuel Huguet
- Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, United Kingdom
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Brustia R, Boleslawski E, Monsel A, Barbier L, Dharancy S, Adam R, Dumortier J, Lesurtel M, Conti F, Scatton O. Definition and Prospective Assessment of Functional Recovery After Liver Transplantation: A New Objective Consensus-Based Metric for Safe Discharge. Liver Transpl 2020; 26:1241-1253. [PMID: 32621369 DOI: 10.1002/lt.25841] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/31/2020] [Accepted: 06/06/2020] [Indexed: 12/11/2022]
Abstract
Standardized discharge criteria are critical to reduce premature discharge and avoid unnecessary hospital stays. No such criteria exist for patients undergoing liver transplantation (LT). To achieve a consensus-based checklist of criteria for safe patient discharge after LT, this mixed-method study included the following: a systematic literature review and expert discussion to draft a first checklist of post-LT discharge criteria, defining patient recovery and indications for hospital discharge (functional recovery); an exploratory online electronic Delphi (e-Delphi) study; a single-center pilot study to test checklist feasibility; and a final e-Delphi study with an extended interdisciplinary expert panel to validate the final checklist. The first round provided a 10-point discharge checklist with 5 patient-centered items derived from discharge criteria after liver surgery and 5 graft-centered items derived from expert discussion. The restricted panel (9 experts) e-Delphi provided 100% consensus after the second round, with slight modifications to the criteria. During the pilot study, 19 of 45 (42.2%) patients included fulfilled the complete checklist (100% of 10 items) after median (IQR) 16 (8-21) days (functional recovery) and a length of stay of 20 (9-24) days. The item with the lowest completion rate was minimum serum tacrolimus level in the target on 2 consecutive blood samples (n = 21; 47%), achieved at 13 (9-15) days. The extended panel (66 experts) e-Delphi provided 95%-98% consensus after the third round, with slight modifications of the criteria. This study provided substantial consensus on discharge criteria after LT. We anticipate that these criteria will be useful in clinical practice to guide patient discharge and increase the comparability of results between future studies.
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Affiliation(s)
- Raffaele Brustia
- Department of Hepatobiliary and Liver Transplantation Surgery, AP-HP, Hôpital Pitié Salpêtrière, CRSA, Sorbonne Université, Paris, France.,Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, AP-HP, Hôpital Pitié Salpêtrière, CRSA, Sorbonne Université, Paris, France
| | - Emmanuel Boleslawski
- Biotherapy (CIC-BTi) and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), AP-HP, Hôpital Pitié Salpêtrière, CRSA, Sorbonne Université, Paris, France
| | - Antoine Monsel
- Hepatology and Liver Transplantation Department, AP-HP, Hôpital Pitié Salpêtrière, CRSA, Sorbonne Université, Paris, France.,Immunology-Immunopathology-Immunotherapy, INSERM, Joint Research Unit in Health 959, Sorbonne Université, Paris, France.,Université de Picardie-Jules Verne, UR UPJV 7518 SSPC, Amiens, France
| | - Louise Barbier
- Laser Assisted Therapies and Immunotherapies for Oncology, U1189, Centre Hospitalier Universitaire Lille, University of Lille, INSERM, Lille, France
| | - Sébastien Dharancy
- Department of Digestive Surgery, Hepatobiliary Surgery and Liver Transplantation, University Hospital of Tours, FHU SUPORT, INSERM 1082, Poitiers, France
| | - René Adam
- Transplantation Unit, University Hospital of Lille, Lille, France
| | - Jérôme Dumortier
- Centre Hepato-Biliaire, AP-HP Paul Brousse Hospital, Paris-Saclay University, Villejuif, France
| | - Mickaël Lesurtel
- Departments of, Department of, Hepatology, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France
| | - Filomena Conti
- Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France
| | - Olivier Scatton
- Department of Hepatobiliary and Liver Transplantation Surgery, AP-HP, Hôpital Pitié Salpêtrière, CRSA, Sorbonne Université, Paris, France
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Darnis B, Mohkam K, Golse N, Vibert E, Cherqui D, Cauchy F, Soubrane O, Regimbeau JM, Dembinski J, Hardwigsen J, Bachelier P, Laurent C, Truant S, Millet G, Lesurtel M, Boleslawksi E, Mabrut JY. Long-term abdominal wall benefits of the laparoscopic approach in liver left lateral sectionectomy: a multicenter comparative study. Surg Endosc 2020; 35:5034-5042. [PMID: 32989540 DOI: 10.1007/s00464-020-07985-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 09/14/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Laparoscopy is nowadays considered as the standard approach for hepatic left lateral sectionectomy (LLS), but its value in the prevention of incisional hernia (IH) has not been demonstrated. METHODS Between 2012 and 2017, patients undergoing laparoscopic (LLLS) or open LLS (OLLS) in 8 centers were compared. Patients undergoing a simultaneous major abdominal procedure were excluded. The incidence of IH was assessed clinically and morphologically on computed tomography (CT) using inverse probability of treatment weighting (IPTW) and multivariable regression analysis. RESULTS After IPTW, 84 LLLS were compared to 48 OLLS. Compared to OLLS, LLLS patients had reduced blood loss (100 [IQR: 50-200] ml vs. 150 [IQR: 50-415] ml, p = 0.023) and shorter median hospital stay (5 [IQR: 4-7] days vs. 7 [6-9] days, p < 0.001), but experienced similar rate of postoperative complications (mean comprehensive complication index: 12 ± 19 after OLLS versus 13 ± 20 after LLLS, p = 0.968). Long-term radiological screening was performed with a median follow-up of 27.4 (12.1-44.9) months. There was no difference between the two groups in terms of clinically relevant IH (10.7% [n = 9] after LLLS, 8.3% [n = 4] after OLLS, p = 0.768). The rate of IH detected on computed tomography was lower after LLLS than after OLLS (11.9% [n = 10] versus 29.2% [n = 14], p = 0.013). On multivariable analysis, the laparoscopic approach was the only independent factor influencing the risk of morphological IH (OR = 0.290 [95% CI: 0.094-0.891], p = 0.031). The 2 preferential sites for specimen extraction after LLLS were Pfannenstiel and midline incisions, with rates of IH across the extraction site of 2.3% [n = 1/44] and 23.8% [n = 5/21], respectively (p = 0.011). CONCLUSION The laparoscopic approach for LLS decreases the risk of long-term IH as evidenced on morphological examinations, with limited clinical impact. Pfannenstiel's incision should be preferred to midline incision for specimen extraction after LLLS.
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Affiliation(s)
- Benjamin Darnis
- Department of General Surgery and Liver Transplantation, Hôpital de La Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, 103 Grande Rue de la Croix-Rousse, 69317, Lyon Cedex 04, France
| | - Kayvan Mohkam
- Department of General Surgery and Liver Transplantation, Hôpital de La Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, 103 Grande Rue de la Croix-Rousse, 69317, Lyon Cedex 04, France. .,Cancer Research Center of Lyon, INSERM 1052/CNRS 5286 Unit, Lyon, France.
| | - Nicolas Golse
- Department of Hepatobiliary Surgery and Liver Transplantation, Hôpital Paul Brousse, Villejuif, France
| | - Eric Vibert
- Department of Hepatobiliary Surgery and Liver Transplantation, Hôpital Paul Brousse, Villejuif, France
| | - Daniel Cherqui
- Department of Hepatobiliary Surgery and Liver Transplantation, Hôpital Paul Brousse, Villejuif, France
| | - François Cauchy
- Department of Hepatobiliary Surgery and Liver Transplantation, Hôpital Beaujon, Clichy, France
| | - Olivier Soubrane
- Department of Hepatobiliary Surgery and Liver Transplantation, Hôpital Beaujon, Clichy, France
| | - Jean-Marc Regimbeau
- Department of Hepatobiliary Surgery, Centre Hospitalier Universitaire D'Amiens, Amiens, France
| | - Jeanne Dembinski
- Department of Hepatobiliary Surgery, Centre Hospitalier Universitaire D'Amiens, Amiens, France
| | - Jean Hardwigsen
- Department of Hepatobiliary Surgery and Liver Transplantation, Hôpital de La Timone, Marseille, France
| | - Philippe Bachelier
- Department of Hepatobiliary Surgery and Liver Transplantation, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Christophe Laurent
- Department of Hepatobiliary Surgery and Liver Transplantation, Hôpital Haut-Lévèque Bordeaux, Pessac, France
| | - Stéphanie Truant
- Department of Hepatobiliary Surgery and Liver Transplantation, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Guillaume Millet
- Department of Hepatobiliary Surgery and Liver Transplantation, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Mickaël Lesurtel
- Department of General Surgery and Liver Transplantation, Hôpital de La Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, 103 Grande Rue de la Croix-Rousse, 69317, Lyon Cedex 04, France.,Cancer Research Center of Lyon, INSERM 1052/CNRS 5286 Unit, Lyon, France
| | - Emmanuel Boleslawksi
- Department of Hepatobiliary Surgery and Liver Transplantation, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Jean-Yves Mabrut
- Department of General Surgery and Liver Transplantation, Hôpital de La Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, 103 Grande Rue de la Croix-Rousse, 69317, Lyon Cedex 04, France.,Cancer Research Center of Lyon, INSERM 1052/CNRS 5286 Unit, Lyon, France
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Giovinazzo F, Kuemmerli C, Moekotte A, Rawashdeh A, Suhool A, Armstrong T, Primrose J, Abu Hilal M. The impact of enhanced recovery on open and laparoscopic liver resections. Updates Surg 2020; 72:649-657. [PMID: 32418169 DOI: 10.1007/s13304-020-00786-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 05/02/2020] [Indexed: 01/11/2023]
Abstract
Enhanced recovery after surgery programs (ERP) have been implemented in many surgical specialties. Their impact in liver surgery is poorly understood and approach-specific ERPs have not yet been assessed. This retrospective study aims to analyse the effect of such programs on liver resection. All patients undergoing liver resection at a tertiary referral centre between January 2009 and April 2019 were identified. Primary outcome was the length of stay (LOS), secondary outcomes were functional recovery, complications and readmission rates. Patients in the ERP with different protocols for open, laparoscopic, major and minor resections were compared to a historical cohort. Of 1056 patients, 644 were treated within the ERP. A comparable duration of hospital stay [7 days (IQR (interquartile range) 6-12) vs 7 days (IQR 5-9) p = 0.047] and faster functional recovery with fewer complications was found in the ERP group [94 (50.5%) vs 103 (35.9%) p < 0.002]. Those advantages were smaller after open minor compared to open major resection. In patients undergoing laparoscopic resection no differences were observed except for a lower readmission rate [21 (9.3%) vs 13 (3.6%) p = 0.005]. Multivariable analysis showed that laparoscopy was associated with a shorter LOS. ERPs offer significant advantages in open liver surgery. Those advantages are less evident after laparoscopic resection.
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Affiliation(s)
- Francesco Giovinazzo
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Christoph Kuemmerli
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, UK
- Department of Surgery, Istituto Fondazione Poliambulanza, Via Bissolati 57, 25124, Brescia, Italy
| | - Alma Moekotte
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Arab Rawashdeh
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Amal Suhool
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Thomas Armstrong
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - John Primrose
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - Mohammed Abu Hilal
- Department of Surgery, University Hospital of Southampton NHS Foundation Trust, Southampton, UK.
- Department of Surgery, Istituto Fondazione Poliambulanza, Via Bissolati 57, 25124, Brescia, Italy.
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Syn NL, Kabir T, Koh YX, Tan HL, Wang LZ, Chin BZ, Wee I, Teo JY, Tai BC, Goh BKP. 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. Ann Surg 2020; 272:253-265. [PMID: 32675538 DOI: 10.1097/sla.0000000000003672] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Nicholas L Syn
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Biostatistics & Modelling Domain, Saw Swee Hock School of Public Health, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tousif Kabir
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Ye Xin Koh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Hwee Leong Tan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Louis Z Wang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Ian Wee
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jin Yao Teo
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Bee Choo Tai
- Biostatistics & Modelling Domain, Saw Swee Hock School of Public Health, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Biostatistics Core, Investigational Medicine Unit, National University Health System, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
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40
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Laparoscopic versus open hemihepatectomy: comprehensive comparison of complications and costs at 90 days using a propensity method. Updates Surg 2020; 72:1041-1051. [PMID: 32734578 PMCID: PMC7680740 DOI: 10.1007/s13304-020-00854-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/21/2020] [Indexed: 02/07/2023]
Abstract
Laparoscopic hemihepatectomy (LHH) may offer advantages over open hemihepatectomy (OHH) in blood loss, recovery, and hospital stay. The aim of this study is to evaluate our recent experience performing hemihepatectomy and compare complications and costs up to 90 days following laparoscopic versus open procedures. Retrospective evaluation of patients undergoing hemihepatectomy at our center 01/2010–12/2018 was performed. Patient, tumor, and surgical characteristics; 90-day complications; and costs were analyzed. Inverse probability of treatment weighting (IPTW) was used to balance covariates. A total of 141 hemihepatectomies were included: 96 OHH and 45 LHH. While operative times were longer for LHH, blood loss and transfusions were less. At 90 days, there were similar rates of liver-specific and surgical complications but fewer medical complications following LHH. Medical complications that arose with greater frequency following OHH were primarily pulmonary complications and urinary and central venous catheter infections. Complications at 90 days were lower following LHH (Clavien–Dindo grade ≥ III OHH 23%, LHH 11%, p = 0.130; Comprehensive Complication Index OHH 20.0 ± 16.1, LHH 10.9 ± 14.2, p = 0.001). While operating costs were higher, costs for hospital stay and readmissions were lower with LHH. Patients undergoing LHH experience a significant reduction in postoperative medical complications and costs, resulting in 90-day cost equity compared with OHH.
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41
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Viannay P, Hamel JF, Bougard M, Barbieux J, Hamy A, Venara A. Gastrointestinal motility has more of an impact on postoperative recovery than you might expect. J Visc Surg 2020; 158:19-26. [PMID: 32624336 DOI: 10.1016/j.jviscsurg.2020.06.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE While patient's reported autonomy (PRA) may help the physician to adapt the day of discharge, the link between postoperative ileus and length of stay and PRA is not known. The aim of this study was to evaluate the evolution of the PRA score during the postoperative period and to determine the factors possibly influencing such an evolution. METHODS This retrospective study on a prospective database took place in a single centre over 14 months. PRA was defined by the by using part I of the Groningen Activity Restriction Scale known as activity of daily life [from 9 (best) to 45 (worst)]. RESULTS Among the 101 patients operated on for elective or emergent colorectal surgery, 80% of the patients had recovered their preoperative PRA (±5 points) before discharge and maintained their PRA during the 2 days preceding discharge. While PRA was significantly decreased by surgery (P<0.0001), each postoperative day allowed for its progressive recovery. Interestingly, the day of recovery of GI transit was associated with a significant increase of PRA (-6.96 points, P<0.0001). Despite high variability of baseline autonomy level, patients presented very similar recovery processes, which were represented by very low slope variability in the linear mixed model. Laparoscopy reduced the decrease of postoperative PRA (P=0.03) while ASA score>2 increased PRA (P=0.03). Age, emergency surgery and the occurrence of postoperative morbidity did not affect postoperative autonomy. Finally, enhanced recovery programs (ERP) tended to improve postoperative autonomy recovery (P=0.09). CONCLUSION PRA may be used as a means of optimising a patient's day of discharge following colorectal surgery.
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Affiliation(s)
- P Viannay
- Department of Endocrinal and Visceral Surgery, Angers University Hospital, 49933 Angers, France; Department of Medicine, Angers University of Health, 49000 Angers, France
| | - J F Hamel
- Department of Medicine, Angers University of Health, 49000 Angers, France; Department of Biostatistics, Maison de la Recherche, Angers University Hospital, 49933 Angers, France
| | - M Bougard
- Department of Endocrinal and Visceral Surgery, Angers University Hospital, 49933 Angers, France; Department of Medicine, Angers University of Health, 49000 Angers, France
| | - J Barbieux
- Department of Endocrinal and Visceral Surgery, Angers University Hospital, 49933 Angers, France; Department of Medicine, Angers University of Health, 49000 Angers, France
| | - A Hamy
- Department of Endocrinal and Visceral Surgery, Angers University Hospital, 49933 Angers, France; Department of Medicine, Angers University of Health, 49000 Angers, France
| | - A Venara
- Department of Endocrinal and Visceral Surgery, Angers University Hospital, 49933 Angers, France; Department of Medicine, Angers University of Health, 49000 Angers, France; UMR INSERM U1235, TENS, The Enteric Nervous System in Gut and Brain Disorders, Institut des Maladies de l'Appareil Digestif, 1, rue Gaston-Veil, 44035 Nantes, France.
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Kohler A, Perrodin S, De Gottardi A, Candinas D, Beldi G. Effectiveness of terlipressin for prevention of complications after major liver resection - A randomized placebo-controlled trial. HPB (Oxford) 2020; 22:884-891. [PMID: 31680011 DOI: 10.1016/j.hpb.2019.10.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 10/01/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Elevated portal pressure in response to major liver resection is associated with impaired liver regeneration and increased postoperative complications. Terlipressin, a splanchnic vasoconstrictor used for treatment of hepatorenal syndrome, was tested for reduction of complications and renal protection after liver resection. METHODS A randomized double-blinded placebo-controlled trial including patients undergoing elective major liver resection was performed. Terlipressin was administered to patients in the intervention group for five days. The primary outcome parameter was the incidence of a clinical composite endpoint of following liver specific complications 6 weeks after surgery: liver failure, ascites, bile leakage, intra-abdominal abscess and operative mortality. Postoperative kidney function was assessed as a secondary endpoint. RESULTS 150 patients (mean age 63.4 years, 73.3% male) were included. No difference was found in the composite endpoint between the placebo and intervention group (32.8% versus 30.8%, relative risk 1.066, 95%CI 0.643 to 1.769, p = 0.85). Patients receiving terlipressin showed a significant lower decrease in postoperative estimated glomerular filtration rate compared to placebo (two way ANOVA, p = 0.005). CONCLUSION Perioperative administration of terlipressin during major liver surgery did not affect a composite endpoint of liver specific complications, but significantly protected from postoperative deterioration of kidney function compared to placebo. CLINICALTRIALS. GOV IDENTIFIER NCT01921985.
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Affiliation(s)
- Andreas Kohler
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Stéphanie Perrodin
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Andrea De Gottardi
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Daniel Candinas
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Guido Beldi
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.
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Fung AKY, Chong CCN, Lai PBS. ERAS in minimally invasive hepatectomy. Ann Hepatobiliary Pancreat Surg 2020; 24:119-126. [PMID: 32457255 PMCID: PMC7271107 DOI: 10.14701/ahbps.2020.24.2.119] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 01/23/2020] [Accepted: 01/29/2020] [Indexed: 02/07/2023] Open
Abstract
Open hepatectomy is associated with significant post-operative morbidity and mortality profile. The use of minimally invasive approach for hepatectomy can reduce the post-operative complication profile and total length of hospital stay. Enhanced recovery after surgery (ERAS) programs involve evidence-based multimodal care pathways designed to achieve early recovery for patients undergoing major surgery. This review will discuss the published evidence, challenges and future directions for ERAS in minimally invasive hepatectomy.
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Affiliation(s)
- Andrew K Y Fung
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Charing C N Chong
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Paul B S Lai
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
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44
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Assis BSD, Coelho FF, Jeismann VB, Kruger JAP, Fonseca GM, Cecconello I, Herman P. Total laparoscopic vs. open liver resection: comparative study with propensity score matching analysis. ACTA ACUST UNITED AC 2020; 33:e1494. [PMID: 32428137 PMCID: PMC7236330 DOI: 10.1590/0102-672020190001e1494] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 01/28/2020] [Indexed: 02/07/2023]
Abstract
Background:
There have been an increasing number of articles that demonstrate the
potential benefits of minimally invasive liver surgery in recent years. Most
of the available evidence, however, comes from retrospective observational
studies susceptible to bias, especially selection bias. In addition, in many
series, several modalities of minimally invasive surgery are included in the
same comparison group. Aim:
To compare the perioperative results (up to 90 days) of patients submitted
to total laparoscopic liver resection with those submitted to open liver
resection, matched by propensity score matching (PSM). Method: Consecutive adult patients submitted to liver resection were included. PSM
model was constructed using the following variables: age, gender, diagnosis
(benign vs. malignant), type of hepatectomy (minor vs. major), and presence
of cirrhosis. After matching, the groups were redefined on a 1:1 ratio, by
the nearest method. Results:
After matching, 120 patients were included in each group. Those undergoing
total laparoscopic surgery had shorter operative time (286.8±133.4 vs.
352.4±141.5 minutes, p<0.001), shorter ICU stay (1.9±1.2 vs. 2.5±2.2days,
p=0.031), shorter hospital stay (5.8±3.9 vs. 9.9±9.3 days, p<0.001) and a
45% reduction in perioperative complications (19.2 vs. 35%, p=0.008). Conclusion:
Total laparoscopic liver resections are safe, feasible and associated with
shorter operative time, shorter ICU and hospital stay, and lower rate of
perioperative complications.
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Affiliation(s)
- Bruno Silva de Assis
- Postgraduate Course in Digestive Surgery, Colégio Brasileiro de Cirurgia Digestiva, São Paulo, Brazil
| | - Fabricio Ferreira Coelho
- Postgraduate Course in Digestive Surgery, Colégio Brasileiro de Cirurgia Digestiva, São Paulo, Brazil
| | - Vagner Birk Jeismann
- Postgraduate Course in Digestive Surgery, Colégio Brasileiro de Cirurgia Digestiva, São Paulo, Brazil
| | | | - Gilton Marques Fonseca
- Postgraduate Course in Digestive Surgery, Colégio Brasileiro de Cirurgia Digestiva, São Paulo, Brazil
| | - Ivan Cecconello
- Department of Gastroenterology, School of Medicine, Universityof São Paulo, São Paulo, Brazil
| | - Paulo Herman
- Department of Gastroenterology, School of Medicine, Universityof São Paulo, São Paulo, Brazil
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A propensity-matched study of full laparoscopic versus hand-assisted minimal-invasive liver surgery. Surg Endosc 2020; 35:2021-2028. [PMID: 32347389 DOI: 10.1007/s00464-020-07597-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/22/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM The implications of multi-incision (MILS) and hand-assisted (HALS) laparoscopic techniques for minimally invasive liver surgery with regard to perioperative outcomes are not well defined. The purpose of this study was to compare MILS and HALS using propensity score matching. METHODS 309 patients underwent laparoscopic liver resections (LLR) between January 2013 and June 2018. Perioperative outcomes were analyzed after a 1:1 propensity score match. Subgroup analyses of matched groups, i.e., radical lymphadenectomy (LAD) as well as resections of posterosuperior segments (VII and/or VIII), were performed. RESULTS MILS was used in 187 (65.2%) and HALS in 100 (34.8%) cases, with a significant decrease of HALS resections over time (p = 0.001). There were no significant differences with regard to age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) Score, previous abdominal surgery and cirrhosis between both groups. Patients scheduled for HALS were characterized by a significantly higher rate of malignant tumors (p < 0.001) and major resections (p < 0.001). After propensity score matching (PMS), 70 cases remained in each group and all preoperative variables as well as resection extend were well balanced. A significantly higher rate of radical LAD (p = 0.039) and posterosuperior resections was found in the HALS group (p = 0.021). No significant differences between the matched groups were observed regarding operation time, conversion rate, frequency of major complications, length of intensive care unit (ICU) stay, overall hospital stay and R1 rate. CONCLUSION Our analysis suggests MILS and HALS to be equivalent regarding postoperative outcomes. HALS might be particularly helpful to accomplish complex surgical procedures during earlier stages of the learning curve.
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Hong SK, Suh KS, Kim KA, Lee JM, Cho JH, Yi NJ, Lee KW. Pure Laparoscopic Versus Open Left Hepatectomy Including the Middle Hepatic Vein for Living Donor Liver Transplantation. Liver Transpl 2020; 26:370-378. [PMID: 31808294 DOI: 10.1002/lt.25697] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 11/26/2019] [Indexed: 12/21/2022]
Abstract
Pure laparoscopic donor hepatectomy (PLDH) has become increasingly accepted in the era of minimally invasive surgeries. However, the outcomes of pure laparoscopic donor left hepatectomy (PLDLH) are relatively less known than for left lateral sectionectomy or right hepatectomy. This study aimed to report our experience with and the outcomes of PLDLH including the middle hepatic vein (MHV) and to compare these outcomes with conventional donor left hepatectomy (CDLH). The medical records of living liver donors between January 2010 and January 2018 at Seoul National University Hospital were retrospectively reviewed. Donors who underwent left hepatectomy including the MHV were included. To minimize selection bias, donors who underwent CDLH after the initiation of the PLDH program were excluded. Finally, there were 18 donors who underwent CDLH and 8 who underwent PLDLH. The median (interquartile range [IQR]) warm ischemia time (11 [10-16] minutes versus 4 [2-7] minutes; P = 0.001) was longer in the PLDLH group than the CDLH group. The total operation time (333 [281-376] minutes versus 265 [255-308] minutes; P = 0.09) and time to remove the liver (245 [196-276] minutes versus 182 [172-205] minutes; P = 0.08) were also longer in PLDLH although not statistically significant. The length of postoperative hospital stay was significantly shorter in the PLDLH group (7 [7-8] days versus 9 [8-10] days; P = 0.01). There were no postoperative complications in the PLDLH group. The rate of complications in recipients was similar in both groups. In conclusion, PLDLH including the MHV appears to be safe and feasible. Further analysis including longterm outcomes is needed.
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Affiliation(s)
- Suk Kyun Hong
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyung-Suk Suh
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyung Ae Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Jeong-Moo Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Jae-Hyung Cho
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Nam-Joon Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Kwang-Woong Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
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Savikko J, Vikatmaa L, Hiltunen AM, Mallat N, Tukiainen E, Salonen SM, Nordin A. Enhanced recovery protocol in laparoscopic liver surgery. Surg Endosc 2020; 35:1058-1066. [PMID: 32107630 PMCID: PMC7886749 DOI: 10.1007/s00464-020-07470-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 02/19/2020] [Indexed: 01/22/2023]
Abstract
Introduction Enhanced recovery protocols (ERP) accelerate recovery and shorten postoperative hospital stay. This increased knowledge of ERPs has also gradually implemented into liver surgery. However, in laparoscopic liver surgery (LLS), the experience of optimized perioperative care protocols is still limited. Methods We prospectively studied the implementation of multimodal ERP principles to LLS in the first 100 consecutive patients. Opioid-sparing multimodal pain management was applied together with early mobilization already in the postoperative care unit (PACU). Drains and catheters were avoided and per oral intake was initiated promptly. Primary pain control was achieved with iv NSAIDS, low-dose opioid and corticosteroids. Combination of per oral ibuprofen and long-acting tramadol was routinely administered shortly after operation. The multiprofessional adherence to the protocol was also evaluated. Results Investigated LLS was performed during Aug 2016–Apr 2019. Operations were done due to malignancy in 83 (83%) of cases, mostly for colorectal liver metastases (n = 52, 52%). Forty-eight (48%) of the operated patients were female. Median age was 65 years (range 17–91). The American Society of Anaesthesiologists Physical Status (ASA) classification median was three. Median postoperative hospital stay was 2 days (range 1–8 days). More than seventy percent of patients were discharged by the second postoperative day and nearly ninety percent by the third postoperative day. Complications after surgery were few. The new ERP elements were adopted in most of the cases. Conclusions ERP was introduced safely and effectively after LLS. The adherence to the ERP was good. Routine discharge 1–2 days after LLS is realistic and achievable.
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Affiliation(s)
- Johanna Savikko
- Department of Transplantation and Liver Surgery, HUS Helsinki University Hospital, Haartmaninkatu 4, P.O. Box 340, 00029, Helsinki, Finland.
| | - Leena Vikatmaa
- Department of Anesthesiology and Intensive Care Medicine, HUS Helsinki University Hospital, Helsinki, Finland
| | - Anna-Maria Hiltunen
- Department of Industrial Engineering and Management, HEMA Institute, Aalto University, Helsinki, Finland.,Nordic Healthcare Group, Helsinki, Finland
| | - Noora Mallat
- Department of Anesthesiology and Intensive Care Medicine, HUS Helsinki University Hospital, Helsinki, Finland
| | - Eija Tukiainen
- Department of Transplantation and Liver Surgery, HUS Helsinki University Hospital, Haartmaninkatu 4, P.O. Box 340, 00029, Helsinki, Finland
| | - Sari-Mari Salonen
- Department of Transplantation and Liver Surgery, HUS Helsinki University Hospital, Haartmaninkatu 4, P.O. Box 340, 00029, Helsinki, Finland
| | - Arno Nordin
- Department of Transplantation and Liver Surgery, HUS Helsinki University Hospital, Haartmaninkatu 4, P.O. Box 340, 00029, Helsinki, Finland
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Srinivasa S, Hughes M, Azodo IA, Adair A, Ravindran R, Harrison E, Wigmore SJ. Laparoscopic liver resection in cirrhotics: feasibility and short-term outcomes compared to non-cirrhotics. ANZ J Surg 2020; 90:1104-1107. [PMID: 32072750 DOI: 10.1111/ans.15745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 01/19/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Laparoscopic liver resection (LLR) is increasingly common worldwide but its suitability in patients with cirrhosis is not clearly defined. There are minimal data in the western literature on this topic and previous work has compared LLR to open hepatectomy rather than to LLR in non-cirrhotic patients. This study compared short-term outcomes of LLR in cirrhotic patients to LLR in non-cirrhotic patients. METHODS Retrospective review of minor LLR at the Royal Infirmary of Edinburgh from January 2006 to January 2018 was conducted. Patients were stratified by whether they had cirrhosis - defined as per radiological appearances and liver function tests. Variables of interest included baseline clinicopathological information with short-term outcomes (length of stay and complications) regarded as the primary outcome of interest. RESULTS Out of 1207 liver resections in the study period, there were 120 LLR with 30 patients having cirrhosis. Patients with cirrhosis were more likely to be male and have higher median American Society of Anesthesiologists scores (3 versus 2; P < 0.01). The most common operation was left lateral sectionectomy (n = 67). There was no difference in duration of surgery (cirrhosis 88 min versus no cirrhosis 99 min; P = 0.64) and patients in the cirrhosis arm had no conversions to open (0% versus 12%; P = 0.06). There was no difference in complications (12% versus 13%; P = 0.75) or median length of stay (4 versus 4 days; P = 0.14) and no difference in survival between both groups. CONCLUSION With careful patient selection, LLR is feasible in patients with cirrhosis and provides comparable outcomes to non-cirrhotic patients undergoing LLR.
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Affiliation(s)
- Sanket Srinivasa
- Department of HPB/Transplant Surgery, Royal Infirmary of Edinburgh, The University of Edinburgh, Edinburgh, UK
| | - Michael Hughes
- Department of HPB/Transplant Surgery, Royal Infirmary of Edinburgh, The University of Edinburgh, Edinburgh, UK
| | - Ijeoma A Azodo
- Department of HPB/Transplant Surgery, Royal Infirmary of Edinburgh, The University of Edinburgh, Edinburgh, UK
| | - Anya Adair
- Department of HPB/Transplant Surgery, Royal Infirmary of Edinburgh, The University of Edinburgh, Edinburgh, UK
| | - Ravi Ravindran
- Department of HPB/Transplant Surgery, Royal Infirmary of Edinburgh, The University of Edinburgh, Edinburgh, UK
| | - Ewen Harrison
- Department of HPB/Transplant Surgery, Royal Infirmary of Edinburgh, The University of Edinburgh, Edinburgh, UK
| | - Stephen J Wigmore
- Department of HPB/Transplant Surgery, Royal Infirmary of Edinburgh, The University of Edinburgh, Edinburgh, UK
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Comparison and validation of three difficulty scoring systems in laparoscopic liver surgery: a retrospective analysis on 300 cases. Surg Endosc 2020; 34:5484-5494. [PMID: 31950272 DOI: 10.1007/s00464-019-07345-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 12/24/2019] [Indexed: 02/07/2023]
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Takaoka M. A commentary on: "Physical recovery after laparoscopic vs. open liver resection - A prospective cohort study" [Int J Surg 2019;72:224-229]. Int J Surg 2019; 74:22. [PMID: 31862256 DOI: 10.1016/j.ijsu.2019.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 12/09/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Makoto Takaoka
- The Third Department of Internal Medicine, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1191, Japan.
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