Risk factors for complications after laparoscopic major hepatectomy

Safety of advanced laparoscopic hepatectomy for elderly patients: a Japanese nationwide analysis

BACKGROUND

Although basic laparoscopic hepatectomy (LH) has become the standard procedure for hepatectomy, the safety of advanced LH remains to be clarified, especially in elderly patients. We investigated the safety of advanced LH in elderly Japanese patients.

METHODS

Elderly patients (≥ 65 years) who underwent advanced LH between 2016 and 2021 were analyzed using a nationwide claims database in Japan. The perioperative outcomes of patients who underwent open hepatectomy (OH group) or LH (LH group) were compared using propensity score matching (PSM). The primary outcome was in-hospital mortality. The E-value method was performed to assess the strength of the outcome point estimates against possible unmeasured confounding factors.

RESULTS

Among 5,021 patients, eligible patients were classified into the OH (n = 4,152) and LH (n = 527) groups. The median patient age was 74 years in both groups. Hepatocellular carcinoma and metastatic liver tumors were the major indications for hepatectomy (OH: 52.5% versus 30.6%; LH: 60.7% versus 26.4%). After PSM, in-hospital mortality rates for OH and LH were 1.7 and 0.76%, respectively. The risk ratio was 0.45 (95% confidence interval, 0.16-1.25; E-value = 3.87). Compared with OH, LH was associated with a longer anesthesia time (411 versus 432 min), lower rate of blood product use (red blood concentrate: 33.5% versus 20.3%; fresh frozen plasma: 29.2% versus 17.1%), and shorter hospital stay (13 versus 12 days).

CONCLUSIONS

In elderly patients, the safety of advanced LH was similar to that of advanced OH, or might be better in Japan under the current policy of hospital accreditation.

Effect of minimally invasive versus open surgery in hepatectomy on postoperative wound complications in patients with hepatocellular carcinoma: A meta-analysis

In a meta-analysis, we assessed the impact of different surgical approaches on the outcome of hepatectomy with hepatocellular carcinoma. Four databases, including PubMed, Embase, Cochrane Library, and the Web of Science, have been critically reviewed through the full literature through June 2023. Eleven related trials were examined once they had met the trial's classification and exclusion criteria, as well as the assessment of the quality. A random effects approach was applied to analysis of operative organ infections, and a fixed-effect model was applied to determine the 95% CI and OR. Analysis of the data was done with RevMan 5.3. Our findings indicated that patients undergoing minimally invasive liver cancer surgery had significantly lower risks of surgical organ infection (OR, 0.35; 95% CI, 0.16-0.77; p = 0.009) and wound infection (OR, 0.19; 95% CI, 0.13-0.28; p < 0.001) compared to those undergoing open surgery. There was no heterogeneity observed between the two groups (I2  = 0) in wound infection. Nevertheless, because of the limited number of randomised controlled trials in this meta-analysis, care should be taken and carefully considered in the treatment of these values. Further high-quality studies involving a large number of samples are needed to validate and reinforce the results.

Predictors of discharge timing and unplanned readmission after laparoscopic liver resection

BACKGROUND

The aim of the study was to determine the predictors of discharge timing and 90-day unplanned readmission after laparoscopic liver resection (LLR).

METHODS

Consecutive LLR performed at the "Institut Mutualiste Montsouris" between 2000 and 2019 were retrieved from a prospectively maintained database. Length of stay (LOS) was stratified according to surgical difficulty and was categorized as early (LOS<25th percentile), routine (25th percentile<75th percentile), and delayed discharge otherwise. Uni-and-multivariate analyses were conducted to determine the factors associated with the time of discharge and 90-day unplanned readmission.

RESULTS

Early discharge occurred in 15.7% patients whereas delayed discharge occurred in 20.6% patients. Concomitant pancreatic resections (OR 26.8, 95% CI 5.75-125, p < 0.0001) and removal of colorectal primary tumors (OR 7.14, 95% CI 3.98-12.8, p < 0.0001) were the strongest predictors of delayed discharge whereas ERP implementation was the strongest predictor of early discharge (OR 7.4, 95% CI 4.60-11.9, p < 0.0001). Unplanned readmission rate was lower among early discharged patients (7.4% vs. 23.8%, p < 0.0001). Bile leakage was the strongest predictor of 90-day unplanned readmission (OR 3.8, 95% CI 1.12-15.8, p = 0.045).

CONCLUSION

Concomitant colorectal or pancreatic resections were the strongest predictors of delayed discharge. Postoperative bile leakage was the strongest predictor of 90-day unplanned readmission following LLR.

Risk factors for the recurrence of early hepatocellular carcinoma treated by percutaneous radiofrequency ablation with a multiple-electrode switching system: a multicenter prospective study

PURPOSE

To investigate the long-term efficacy of radiofrequency ablation (RFA) with a multiple-electrode switching system (MESS) in the treatment of early hepatocellular carcinoma (HCC) and evaluate the patterns and risk factors of intrahepatic recurrence of HCC after RFA.

METHODS

In total, 139 patients with early HCC who underwent RFA with MESS as primary treatment at multiple centers were prospectively enrolled according to the inclusion criteria. We evaluated the local tumor progression (LTP), intrahepatic distant recurrence (IDR), the incidence of cumulative disease-free survival (DFS), LTP-free survival, IDR-free survival, and overall survival. We also analyzed the associated risk factors.

RESULTS

A total of 139 patients were included in the study and the median follow-up time was 64 months, ranging from 11 to 72 months. The complete ablation rate was 98.56%. Sixty-nine (49.64%) were found to have intrahepatic recurrence (LTP, n = 15; IDR, n = 55) during follow-up. The 1-year, 3-year and 5-year cumulative DFS, LTP-free survival, and IDR-free survival rates were 74.82, 94.46 and 78.75%; 54.68, 88.03 and 61.79%; and 51.80, 85.67 and 60.17%, respectively. In the multivariable analysis, tumor size > 4 cm was the only important risk factor for LTP. The alkaline phosphatase (ALP) level and the number of tumors were independent risk factors for IDR; α-fetoprotein (AFP) level > 400 µg/L and recurrence interval were risk factors for the overall survival period.

CONCLUSIONS

The MESS-RFA is an effective method for local control of tumors in early HCC. Early HCC with multiple high-ALP tumors has a higher rate of recurrence, which mainly occurs in an IDR pattern. Early HCC with high AFP levels and a shorter initial recurrence interval resulted in a poorer prognosis. Thus, treatments such as liver transplantation or surgical resection may be a good strategy in those cases.

CLINICALTRIALS.GOV ID

NCT02046356.

Minimally invasive versus open living donors right hepatectomy: A systematic review and meta-analysis

BACKGROUND

Although minimally invasive technology has been widely used in hepatectomy, it remains controversial with regards to liver transplantation, especially in donors right hepatectomy. Herein, we compared the short-term safety and efficacy of minimally invasive donors right hepatectomy (MIDRH) with open donors right hepatectomy (ODRH).

METHODS

A systematic literature search was carried out using PubMed, Embase, Web of Science and the Cochrane Library database in order to identify comparison studies of MIDRH and ODRH. Next, we obtained the relevant data, and carried out the meta-analysis.

RESULTS

This meta-analysis included 12 studies, which included 1755 cases that underwent donors right hepatectomy. Compared to ODRH, patients that underwent MIDRH had less bleeding (SWD = -0.52, p<0.001), shorter hospital stays (SWD = -0.58, p < 0.001) and lower overall postoperative complications of donors (RR = 0.74, p = 0.008). However, MIDRH was found to be associated with prolonged operative times (SWD = 0.74, p < 0.001), as well as a higher rate of biliary complications in donors (RR = 2.26, p = 0.007) and recipients (RR = 1.69, p < 0.001). There were no statistically significant differences between MIDRH and ODRH in postoperative liver function, rate of major complications and vascular complications of both donors and recipients and overall postoperative complications.

DISCUSSION

MIDRH is superior to ODRH with regards to intraoperative bleeding, postoperative hospital stay and overall donor complications. Although biliary-related complications are higher, it is feasible to develop MIDRH in experienced liver transplant centers. However, higher-quality research is still needed for corroboration.

Rationality and necessity of vascular stapler application during liver resection (Review)

Liver resection (LR) is the primary treatment method for patients with hepatocellular carcinoma (HCC). Improving surgical safety and reducing surgical morbidity and mortality is important for patients receiving LR. Various devices have been developed to facilitate vascular transection to reduce intraoperative blood loss, which is considered to be a predictor of poor surgical outcomes in patients undergoing LR. Vascular staplers have been widely applied for the division of major vascular and biliary structures in the process of LR; however, when and how to use these tools remains controversial. This review aims to report the rationality and necessity of using vascular staplers in vessel transection during liver surgery. Due to the risk of intraoperative and postoperative hemorrhage and biliary fistula, the process of transection of the portal pedicle and hepatic vein is a crucial step during LR. Stapling represents a vascular dissection technique that is widely used in laparoscopic LR and has then been popularized in open LR. Advocates argue that stapler transection methods provide several advantages, including diminished blood loss, fewer transfusion requirements and shorter operative times. However, other studies have failed to demonstrate those benefits when using these tools compared with the simple clamp-crushing technique. Using the stapler vascular transection method resulted in smaller surgical margins and similar surgical outcomes compared with those of the clamp-crushing vascular transection method. However, the intraoperative use of vascular staplers may significantly increase the financial burden of liver resection for patients with HCC, while not improving short- and long-term outcomes. Therefore, it has been suggested that vascular staplers should not be routinely used in LR. The current review discussed the above points and recommended that the stapling transection of the portal pedicle and hepatic vein should be applied during laparoscopic LR in a rational manner. However, the suturing ligation method should be routinely used in open LR.

Operative Time, Age, and Serum Albumin Predict Surgical Morbidity After Laparoscopic Liver Surgery

Background. Laparoscopic liver resection (LLR) has emerged as a considerable alternative to conventional liver surgery. However, the increasing complexity of liver resection raises the incidence of postoperative complications. The aim of this study was to identify risk factors for postoperative morbidity in a monocentric cohort of patients undergoing LLR. Methods. All consecutive patients who underwent LLR between 2015 and 2019 at our institution were analyzed for associations between complications with demographics and clinical and operative characteristics by multivariable logistic regression analyses. Results. Our cohort comprised 156 patients who underwent LLR with a mean age of 60.0 ± 14.4 years. General complications and major perioperative morbidity were observed in 19.9% and 9.6% of the patients, respectively. Multivariable analysis identified age>65 years (HR = 2.56; P = .028) and operation time>180 minutes (HR = 4.44; P = .001) as significant predictors of general complications (Clavien ≥1), while albumin<4.3 g/dl (HR = 3.66; P = .033) and also operative time (HR = 23.72; P = .003) were identified as predictors of major postoperative morbidity (Clavien ≥3). Conclusion. Surgical morbidity is based on patient- (age and preoperative albumin) and procedure-related (operative time) characteristics. Careful patient selection is key to improve postoperative outcomes after LLR.

Propensity score matching analysis for outcomes of laparoscopic versus open caudate lobectomy

BACKGROUND

To date, laparoscopic caudate lobectomy (LCB) remains a challenge, and evidence about its value is rare. Therefore, this study was performed to assess the benefits of LCB for patients with tumours located in the caudate lobe compared with open caudate lobectomy (OCB).

METHODS

From October 2015 to June 2019, 102 patients meeting the inclusion and exclusion criteria were eligible for this study. The patients were divided into LCB and OCB groups. Short-term outcomes between the groups were compared with propensity score matching (PSM).

RESULTS

LCB was performed in 31 of the 102 included patients. After PSM, 30 patients with well-balanced baseline levels were enrolled in each group. Intraoperative blood loss in the LCB group was less than that in the OCB group (median, 100 versus 200 mL, P = 0.017), even though it did not reach a statistically significant difference after PSM (median, 100 versus 187.5 mL, P = 0.085). Moreover, although post-operative overall complications were similar in the two groups, a tendency of lower rates of respiratory infection in the LCB group than the OCB group was observed (0% versus 12.7%, P = 0.054 before PSM; 0% versus 16.7%, P = 0.063 after PSM). There was no early mortality in either group. LCB had a shorter post-operative hospital stay than OCB (median, 5 versus 6 days, P < 0.001). However, the hospitalization cost was higher in the LCB group than in the OCB group (P < 0.001).

CONCLUSION

LCB is safe and feasible in selected patients when performed by experienced surgeons.

Transitioning From Open to Robotic Liver Resection. Results of 46 Consecutive Procedures Including a Majority of Major Hepatectomies

Aims. Minimally invasive liver resection is a complex and challenging operation. Although authors have reported robotic liver resection shows improved safety and efficacy compared with open liver resection, robotic major liver resections for malignant liver lesions treatment remain inadequately evaluated. The aims of the present study were to evaluate the feasibility and safety of transitioning from open to robotic liver resection in a nonuniversity hospital. Patients and Methods. From December 2015 to March 2020, 46 patients underwent totally robotic-assisted liver resections out of 446 robotic procedures. Also, we retrospectively reviewed the last 27 open right hepatectomies (ORHs) and compared then with the first 25 anatomic robotic-assisted right hepatectomies (RRHs). Results. Mean operative time, mean blood lost, rate of complications, and mean hospital stay were associated with the complexity of the procedure. The comparison between ORH and RRH showed that intraoperative complications were less frequently observed during ORH whereas RRH showed a trend in favor of less blood loss. ORH had a trend toward smaller surgical margins and higher rate of R1 resections. Recurrence occurred in 31 (59%) patients and was more frequently observed after ORH. However, the mean follow-up was significantly shorter after RRH. Conclusion. Our study demonstrated the technical feasibility and safety of transitioning from open to robotic liver resection (including major hepatectomies) in a nonuniversity setting. Higher costs remain an important drawback for robotic surgery.

Radiofrequency ablation versus laparoscopic hepatectomy for treatment of hepatocellular carcinoma: a systematic review and meta-analysis

Background

Several randomized controlled trials (RCTs) compared the effects of laparoscopic hepatectomy (LH) and radiofrequency ablation (RFA) for the treatment of hepatocellular carcinoma (HCC), but the results have remained inconsistent. Hence, a meta-analysis and a systematic review of these treatment modalities are necessary to evaluate their efficacy and safety for HCC treatment.

Methods

From the inception of this meta-analysis and review until August 31, 2019, we searched Medline, PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure, Wanfang Database, and China Biomedical Literature Database for RCTs involving LH and RFA treatments of patients with HCC. The studies were screened and the data from these articles were extracted independently by two authors. Summary odd ratios (OR) or mean differences (MD) with 95% confidence intervals (CI) were calculated for each outcome with a fixed- or random-effect model. The outcomes for effectiveness evaluations included duration of surgery, estimated bleeding volume, incidence of blood transfusion during surgery, duration of hospital stay, and the outcome for safety included the incidence of cancer recurrence.

Results

Seven RCTs with a total of 615 patients were identified, 312 and 303 of which underwent RFA and LH treatments, respectively. The duration of surgery (MD = −99.04; 95% CI: −131.26–−66.82), estimated bleeding volume (MD = −241.97; 95% CI: −386.93–−97.02), incidence of blood transfusion during surgery (OR = 0.08; 95% CI: 0.02–0.37), and duration of hospital stay (MD = −3.4; 95% CI: −5.22–−1.57) in RFA treatment were significantly lower than those of LH treatment. However, the incidence of cancer recurrence was significantly higher for RFA treatment compared with LH treatment (OR = 2.68; 95% CI: 1.72–4.18).

Conclusions

LH treatment is preferred over RFA treatment with a better radical effect, but RFA treatment is more beneficial with smaller trauma, development of less complications, and shorter operating time when compared with HCC treatment.

Laparoscopic major hepatectomy for hepatocellular carcinoma in elderly patients: a multicentric propensity score‑based analysis

BACKGROUND

Considering the increase in overall life expectancy and the rising incidence of hepatocellular carcinoma (HCC), more elderly patients are considered for hepatic resection. Traditionally, major hepatectomy has not been proposed to the elderly due to severe comorbidities. Indeed, only a few case series are reported in the literature. The present study aimed to compare short-term and long-term outcomes between laparoscopic major hepatectomy (LMH) and open major hepatectomy (OMH) in elderly patients with HCC using propensity score matching (PSM).

METHODS

We performed a multicentric retrospective study including 184 consecutive cases of HCC major liver resection in patients aged ≥ 70 years in _8 European Hospital Centers. Patients were divided into LMH and OMH groups, and perioperative and long-term outcomes were compared between the 2 groups.

RESULTS

After propensity score matching, 122 patients were enrolled, 38 in the LMH group and 84 in the OMH group. Postoperative overall complications were lower in the LMH than in the OMH group (18 vs. 46%, p < 0.001). Hospital stay was shorter in the LMH group than in the OMH group (5 vs. 7 days, p = 0.01). Mortality at 90 days was comparable between the two groups. There were no significant differences between the two groups in terms of overall survival (OS) and disease-free survival (DFS) at 1, 3, and 5 years.

CONCLUSION

LMH for HCC is associated with appropriate short-term outcomes in patients aged ≥ 70 years as compared to OMH. LMH is safe and feasible in elderly patients with HCC.

Laparoscopic major liver resections: Current standards

Laparoscopic liver resection was slow to be adopted in the surgical arena at the beginning as there were major barriers including the fear of gas embolism, risk of excessive blood loss from the inability to control bleeding vessels effectively, suboptimal surgical instruments to perform major liver resection and the concerns about oncological safety of the procedure. However, it has come a long way since the early 1990s when the first successful laparoscopic liver resection was performed, spurring liver surgeons worldwide to start exploring the roles of laparoscopy in major liver resections. Till date, more than 9000 cases have been reported in the literature and the numbers continue to soar as the hepatobiliary surgical communities quickly learn and apply this technique in performing major liver resection. Large bodies of evidence are available in the literature showing that laparoscopic major liver resection can confer improved short-term outcomes in terms of lesser operative morbidities, lesser operative blood loss, lesser post-operative pain and faster recovery with shorter length of hospitalization. On the other hand, there is no compromise in the long-term and oncological outcomes in terms of comparable R₀ resection rate and survival rates of this approach. Many innovations in laparoscopic major hepatectomies for complex operations have also been reported. In this article, we highlight the journey of laparoscopic major hepatectomies, summarize the technical advancement and lessons learnt as well as review the current standards of outcomes for this procedure.

Does the difficulty grade of laparoscopic liver resection for colorectal liver metastases correlate with long-term outcomes?

INTRODUCTION

Prognosis of patients with colorectal liver metastases (CRLM) is strongly correlated with the oncological outcome after liver resection. The aim of this study was to analyze the impact of laparoscopic liver resection (LLR) difficulty score (IMM difficulty score) on the oncological results in patients treated for CRLM.

METHODS

All patients who underwent LLRs for CRLM from 2000 to 2016 in our department, were retrospectively reviewed. Data regarding difficulty classification, -according to the Institute Mutualiste Montsouris score (IMM)-, recurrence rate, recurrence-free survival (RFS), overall survival (OS) and data regarding margin status were analyzed.

RESULTS

A total of 520 patients were included. Patients were allocated into 3 groups based on IMM difficulty score of the LLR they underwent: there were 227 (43,6%), 84 (16,2%) and 209 (40,2%) patients in groups I, II and III, respectively. The R₁ resection rate in group I, II and III were 8,8% (20/227), 11,9% (10/84) and 12,4% (26/209) respectively (p = 0.841). Three- and 5-year RFS rates were 77% and 73% in group I, 58% and 51% in group II, 61% and 53% in group III, respectively (p = 0.038). Three and 5-year OS rates were 87% and 80% for group I, 77% and 66% for group II, 80% and 69% for group III respectively (p = 0.022).

CONCLUSION

The higher LLR difficulty score correlates with significant morbidity and worse RFS and OS, although the more technically demanding and difficult cases are not associated with increased rates of positive resection margins and recurrence.

Laparoscopic versus open major liver resection for hepatocellular carcinoma: systematic review and meta-analysis of comparative cohort studies

Background

The application of laparoscopic liver resection (LLR) has expanded rapidly in recent decades. Although multiple authors have reported LLR shows improved safety and efficacy in treating hepatocellular carcinoma (HCC) compared with open liver resection (OLR), laparoscopic (LMLR) and open (OMLR) major liver resections for HCC treatment remain inadequately evaluated. This work aimed to test the hypothesis that LMLR is safer and more effective than OMLR for HCC.

Methods

Comparative cohort and registry studies on LMLR and OMLR, searched in PubMed, the Science Citation Index, EMBASE, and the Cochrane Library, and published before March 31, 2018, were collected systematically and meta-analyzed. Fixed- and random-effects models were employed for generating pooled estimates. Heterogeneity was assessed by the Q-statistic.

Results

Nine studies (1173 patients) were included. Although the pooled data showed operation time was markedly increased for LMLR in comparison with OMLR (weighted mean difference [WMD] 74.1, 95% CI 35.1 to 113.1, P = 0.0002), blood loss was reduced (WMD = − 107.4, 95% CI − 179.0 to − 35.7, P = 0.003), postoperative morbidity was lower (odds ratio [OR] 0.47, 95% CI 0.35 to 0.63, P <  0.0001), and hospital stay was shorter (WMD = − 3.27, 95% CI − 4.72 to − 1.81, P <  0.0001) in the LMLR group. Although 1-year disease-free survival (DFS) was increased in patients administered LMLR (OR = 1.55, 95% CI 1.04 to 2.31, P = 0.03), other 1-, 3-, and 5-year survival outcomes (overall survival [OS] and/or DFS) were comparable in both groups.

Conclusions

Compared with OMLR, LMLR has short-term clinical advantages, including reduced blood loss, lower postsurgical morbidity, and shorter hospital stay in HCC, despite its longer operative time. Long-term oncological outcomes were comparable in both groups.

Perioperative and long-term outcomes of laparoscopic liver resections for non-colorectal liver metastases

BACKGROUND

Liver is a common metastatic site not only of colorectal but of non-colorectal neoplasms, as well. However, resection of non-colorectal liver metastases (NCRLMs) remains controversial. The aim of this retrospective study was to analyze the short- and long-term outcomes of patients undergoing laparoscopic liver resection (LLR) for NCRLMs.

METHODS

From a prospectively maintained database between 2000 and 2018, patients undergoing LLR for colorectal liver metastases (CRLMs) and NCRLMs were selected. Clinicopathologic, operative, short- and long-term outcome data were collected, analyzed, and compared among patients with CRLMs and NCRLMs.

RESULTS

The primary tumor was colorectal in 354 (82.1%), neuroendocrine in 21 (4.9%), and non-colorectal, non-neuroendocrine in the remaining 56 (13%) patients. Major postoperative morbidities were 12.7%, 19%, and 3.6%, respectively (p = 0.001), whereas the mortality was 0.6% for patients with CRLMs and zero for patients with NCRLMs. The rate of R₁ surgical margin was comparable (p = 0.432) among groups. According to the survival analysis, 3- and 5-year recurrence-free survival (RFS) rates were 76.1% and 64.3% in the CRLM group, 57.1% and 42.3% in the neuroendocrine liver metastase (NELM) group, 33% and 20.8% in the non-colorectal, non-neuroendocrine liver metastase (NCRNNELM) group (p = 0.001), respectively. Three- and 5-year overall survival (OS) rates were 88.3% and 82.7% in the CRLM group, 85.7% and 70.6% in the NELM group, 71.4% and 52.9% in the NCRNNELM group (p = 0.001), respectively. In total, 113 out of 354 (31.9%) patients with CRLMs, 2 out of 21(9.5%) with NELMs, and 8 out of 56 (14.3%) patients with NCRNNELMs underwent repeat LLR for recurrent metastatic tumors.

CONCLUSION

LLR is safe and feasible in the context of a multimodal management where an aggressive surgical approach, necessitating even complex procedures for bilobar multifocal metastases and repeat hepatectomy for recurrences, is the mainstay and may be of benefit in the long-term survival, in selected patients with NCRNNELMs.

Does liver cirrhosis have an impact on the results of different hepatic inflow occlusion methods in laparoscopic liver resection? a propensity score analysis

BACKGROUND

Few studies have analyzed the impact of liver cirrhosis on different hepatic inflow occlusion methods in laparoscopic liver resection (LLR). Intermittent Pringle (IP) was compared to continuous hemihepatic vascular inflow occlusion (CHVIO) in LLR in patients with or without cirrhosis.

METHODS

Patients who underwent LLR at the West China Hospital of Sichuan University form January 2015 to October 2017 were grouped according to occlusion methods and severity of cirrhosis. A matched propensity score analysis was performed.

RESULTS

Among patients without cirrhosis, there were no significant differences in blood loss (238 ± 30 ml VS 265 ± 46 ml, P = 0.653), operative time (228 ± 9 min VS 265 ± 20 min, P = 0.437) or other postoperative results between the IP and CHVIO groups after propensity score matching. Among patients with cirrhosis, blood loss (279 ± 24 ml VS 396 ± 35 ml, P = 0.012) and operative time (237 ± 11 min VS 285 ± 24 min, P = 0.041) were significantly lower in the IP group, while postoperative liver function did not significantly differ between the two groups after propensity score matching.

CONCLUSIONS

In patients without cirrhosis, IP is as efficient and as safe as CHVIO in cirrhotic patients. IP offers the advantages of shorter operative time and less blood loss and does not result in worse postoperative liver function.

Liver resection for extra-pancreatic biliary cancer: what is the role of laparoscopic approach?

BACKGROUND

Laparoscopic liver resection (LLR) has evolved over time, yet its role in extra-pancreatic biliary cancer has been limited due to several factors. We aimed to evaluate the short-term outcome of LLR in extra-pancreatic biliary tract cancer.

METHODS

From January 2002 to 2016, all patients who underwent LLR for extra-pancreatic biliary tract cancer including gallbladder cancer (GBC), intra-hepatic cholangiocarcinoma (ICC), and peri-hilar cholangiocarcinoma (PHC) with curative intent (R0 or R1) at Institute Mutualiste Montsouris were identified from prospectively collected databases. Patient characteristics, and perioperative outcomes, were analyzed in all three groups.

RESULTS

A total of 35 patients were included: 10 with GBC, 14 with ICC, and 11 with PHC. There were 19 (54%) women and median age was 71 years. Median operative time was 240 min, and estimated blood loss was 200 ml. Conversion to an open procedure was more common in patients with PHC (45% vs. 7% for ICC and 0% for GBC, p = 0.010). R0 resection was achieved in 10 (100%), 12 (86%), and 8 (73%) patients in GBC, ICC, and PHC groups, respectively (p = 0.204). Postoperative morbidity was reported in 19 (54%) patients of whom 12 (34%) had minor complications. Postoperative mortality was reported in 4 (11%) patients; one (7%) in GBC group, one (7%) in ICC group, and two (18%) in PHC, p = 0.681. Median hospital stay was 11 days.

CONCLUSIONS

The present series suggests that LLR is feasible in GBC, challenging but achievable in ICC but unsuitable for the moment in PHC.

Impact of technical innovation on surgical outcome of laparoscopic major liver resection: 10 years' experience at a large-volume center

Purpose

Laparoscopic major liver resection (major LLR) remains a challenging procedure because of the technical difficulty. Several significant technical innovations have been applied in our center since 2012. They include routine application of bipolar electrocautery, initiation of temporary increase of intra-abdominal pressure during bleeding events from veins to balance the central venous pressure, and use of temporary inflow control of the Glissonean pedicle. This study evaluated the impact of these technique modifications in patients with major LLR.

Methods

Between January 2004 and February 2015, a total of 606 patients underwent LLR at Samsung Medical Center in Seoul, Korea. Major LLR was employed in 233 cases. All major LLR procedures were anatomical resections performed with a totally laparoscopic approach. We compared surgical parameters of right hepatectomy (RH), left hepatectomy (LH), and right posterior sectionectomy (RPS) before and after 2012.

Results

Open conversion rates of RH and LH and estimated blood loss in RPS significantly decreased after 2012. The postoperative complication rate of major LLR was 12.7% and was similar before and after 2012. Bile leakage was the most common complication (3.2%).

Conclusion

The modifications of surgical techniques resulted in good outcomes for laparoscopic major LLR. We recommend routine application of these techniques to improve outcomes, especially in patients requiring major liver resection.

Laparoscopic extended liver resection: are postoperative outcomes different?

BACKGROUND

Although laparoscopic major hepatectomy (LMH) is becoming increasingly common in specialized centers, data regarding laparoscopic extended major hepatectomies (LEMH) and their outcomes are limited. The aim of this study was to compare the perioperative characteristics and postoperative outcomes of LEMH to standard LMH.

METHODS

All patients who underwent purely laparoscopic anatomical right or left hepatectomy and right or left trisectionectomy between February 1998 and January 2016 are enrolled. Demographic, clinicopathological, and perioperative factors were collected prospectively and analyzed retrospectively. Perioperative characteristics and postoperative outcomes in LEMH were compared to those of standard LMH.

RESULTS

Among 195 patients with LMH, 47 (24.1%) underwent LEMH, colorectal liver metastases representing 66.7% of all indications. Preoperative portal vein embolization was undertaken in 31 (15.9%) patients. Despite more frequent vascular clamping, blood loss was higher in LEMH group (400 vs. 214 ml; p = 0.006). However, there was no difference in intraoperative transfusion requirements. Thirty-one patients experienced liver failure with no differences between LMH and LEMH groups. Postoperative mortality was comparable in the two groups [3 (2.5%) LMH patients vs. 2 (5%) LEMH patients (p = 0.388)]. Overall morbidity was higher in the LEMH group [49 LMH patients (41.5%) vs. 24 LEMH patients (60%) (p = 0.052)]. Patients treated with left LEMH experienced more biliary leakage (p = 0.011) and more major pulmonary complications (p = 0.015) than left LMH.

CONCLUSION

LEMH is feasible at the price of important morbidity, with manageable and acceptable outcomes. These exigent procedures require high-volume centers with experienced surgeons.

Recurrence patterns after laparoscopic resection of colorectal liver metastases

BACKGROUND

The major issue after liver resection for colorectal liver metastases (CRLM) is the high incidence of recurrence. Unlike open liver resection (OLR), recurrence following laparoscopic liver resection (LLR) is not well documented. The aim of this study was to analyze recurrence patterns and treatment following LLR for CRLM.

STUDY DESIGN

All patients who underwent LLR for CRLM from 2000 to 2016 were reviewed. Patients who presented with recurrence were compared to those who did not. Recurrence-free survival (RFS), overall survival (OS), and risk of recurrence and survival prognostic factors were analyzed.

RESULTS

Overall, 273 patients were included, of which 157 (57.5%) were treated for one liver metastasis (LM). Median follow-up was 41 (12-187) months and associated extrahepatic disease was present in 27% of patients (mainly pulmonary, 65%). After a median of 16 (3-151) months, 197 (72%) patients presented with recurrence. Recurrences were early (< 6 months) in 22.8% of cases, occured in a single site in 66% and were intrahepatic, extrahepatic, or both in 44, 30, and 26%, respectively. Recurrences were treated with surgery or chemotherapy only in 45 and 47%, respectively. 3-, 5-, and 10-year OS was 82, 71, and 43%, respectively. Independent risk factors for recurrence were node-positive primary tumor, extrahepatic disease before hepatectomy, and R1 resection.

CONCLUSION

LLR for CRLM does not seem to be associated with distinctive recurrence patterns. LLR for CRLM yielded satisfying RFS and OS and should therefore be considered whenever possible.

Laparoscopic versus open major hepatectomy: a systematic review and meta-analysis of individual patient data

BACKGROUND

The role of laparoscopy for major hepatectomies remains a matter of development to be further assessed. The purpose of this study is to compare the short- and long-term outcomes between laparoscopic and open major hepatectomies meta-analyzing individual patient data from published comparative studies.

METHODS

All retrospective studies comparing between laparoscopic and open major hepatectomies published until March 2017 were identified independently by 2 reviewers by searching in PubMed and Cochrane Central Register of Controlled Trials. Individual patient data were sought from all selected studies. Postoperative outcomes, including intraoperative blood loss, operative time, hospital stay, postoperative complications, mortality rates, and long-term survival were analyzed.

RESULTS

A total of 917 patients were divided into the laparoscopic (427) and open (490) groups from 8 selected studies. The hospital stay was significantly shorter, and the total morbidity was lower in the laparoscopic group. When classified by severity, the incidence of postoperative minor complications was lower; however, that of major complications was not significantly different. The operative time was longer in the laparoscopic group; however, intraoperative blood loss, perioperative mortality, and blood transfusions were comparable between the 2 groups. The overall survival in the patients with colorectal liver metastases and hepatocellular carcinoma was not significantly different between the 2 groups.

CONCLUSION

Laparoscopic major hepatectomies offer some perioperative advantages, including fewer complications and shorter hospital stay, without increasing the blood loss volume and mortality. Whether these results can anticipate the outcomes in future randomized controlled trials has not been determined.

Systematic review of the feasibility and future of laparoscopic liver resection for difficult lesions

Laparoscopic liver resection (LLR) is now performed widely, but is difficult to accomplish in some anatomical locations, such as the posterosuperior segments (S7 and S8) and caudate lobe (S1). An international survey revealed that lesions in these locations are less frequently indicated for LLR than those in other segments. Recent reports from experienced centers document several case series and present technical tips for treating such lesions. The lateral approach using intercostal (transdiaphragmatic) trocars was reported to be useful for lesions in the posterosuperior segments with a semi- to full-decubitus position. The thoracoscopic approach was also reported to be useful for lesions just under the diaphragm dome, but the tumor location and patient selection should be considered carefully because pneumoperitoneum pressure and Pringle's maneuver cannot be applied. Several case series have described the feasibility of LLR for caudate lobe lesions, with similar operative outcomes to lesions in the posterosuperior segments, but this demands technical expertise. The caudal view of laparoscopy is advantageous for approaching the caudate lobe. We conducted a systematic review to clarify the feasibility of LLR for difficult lesions and discuss its current and future status.

Laparoscopic left liver resections: how far can we go?

INTRODUCTION

The aim of this study was to analyse the outcomes of laparoscopic anatomic hepatectomies of the left liver segments.

METHODS

This is a retrospective multicentre study including all patients operated on laparoscopically divided into unisegmentectomy of 2, 3 or 4 (Group 1), left lobectomy (or left lateral sectionectomy LLS) (Group 2), left hepatectomy (Group 3) and extended left hepatectomy (Group 4) between 2000 and 2016. These four groups were compared in terms of demographics, intraoperative data and postoperative outcomes.

RESULTS

Among the 190 selected patients, the groups 1, 2, 3, 4 included 25 (13.2%), 116 (61.0%), 27 (14.2%) and 22 (11.6%) patients, respectively. The cohorts were comparable except for the number of lesions (p = 0.001) and tumour diameter (p = 0.004). The operative time, blood loss and the use of vascular clamping were more frequent in the Groups 3 and 4 (p = 0.0001), as is the rate of conversion to laparotomy (p = 0.001). Total morbidity was 23.3%, and major complications were more frequent in Group 4 (p = 0.0001). The prevalence of hepatic complications (11.6%), intra-abdominal collections (7.4%) and respiratory complications (3.7%) was proportionally correlated to the hepatectomy extension (p = 0.0001).

CONCLUSION

All laparoscopic left liver resections seem safe and feasible even though extended hepatectomy is associated with a significant morbidity.

Validation of a Difficulty Scoring System for Laparoscopic Liver Resection: A Multicenter Analysis by the Endoscopic Liver Surgery Study Group in Japan

BACKGROUND

Laparoscopic liver resection (LLR) is widely used for hepatic disease treatment. Preoperative prediction of operative difficulty can be beneficial as a roadmap for surgeons advancing from simple to highly technical LLR. We performed a multicenter analysis to investigate a "difficulty scoring system" for predicting the difficulty of LLR.

STUDY DESIGN

The proposed "difficulty scoring system" includes 3 difficulty levels based on 5 factors. The system was validated in a cohort of 2,199 patients who underwent LLR at 74 Japanese centers between 2010 and 2014; the difficulty level was rated as low (n = 965), intermediate (n = 891), and high (n = 343). Operative parameters, postoperative complications, and outcomes were compared according to the difficulty levels.

RESULTS

The median operation time and blood loss were 258 minutes (range 30 to 1,275 minutes) and 75 mL (range 0 to 7,798 mL), respectively. The overall conversion rate was 5.0% (n = 110). The incidences of postoperative complications, liver failure, and in-hospital death were 5.3% (n = 116), 1.5% (n = 32), and 0.5% (n = 12), respectively. Median hospital stay was 9 days (range 1 to 189 days). Conversion rate, operation time, and blood loss showed a direct correlation with the difficulty level. A strong correlation was observed among the difficulty level, incidence of postoperative complications, and hospital stay. Incidence of postoperative liver failure and in-hospital death in the high difficulty group was higher than that in the low difficulty group.

CONCLUSIONS

Preoperative evaluation with the "difficulty scoring system" predicted the difficulty of the operation and the postoperative outcomes of LLR. In the beginning of LLR training, surgeons should start with low difficulty-level operations.

Outcomes of Laparoscopic Liver Resection for Patients with Large Colorectal Liver Metastases: A Case-Matched Analysis

BACKGROUND

Despite the expansion of laparoscopic approach in the treatment of liver tumors, limited data have been reported regarding large colorectal liver metastases (CRLMs). This study aimed at assessing the short- and long-term outcomes after laparoscopic liver resection (LLR) for large (≥5 cm) CRLMs.

METHODS

This was a case-matched study (1:2) comparing patients with large (group L; ≥5 cm) and small (group S; <5 cm) CRLMs using demographic, tumor, and surgical characteristics as matching variables. Postoperative outcomes and survival data were compared in the 2 groups.

RESULTS

Forty patients who underwent LLR for large CRLMs were matched with 80 patients with tumors <5 cm. Major hepatectomy was performed with 75.0 % of patients in Group L and 66.3 % in group S (p = 0.403). Operative time was 300 min in group L and 240 min in group S (p = 0.059). The postoperative mortality and overall morbidity rates were comparable in the 2 groups (p = 1.000 and 0.170, respectively). Postoperative major complication (Dindo-Clavien ≥3) was similar between the two groups (p = 0.072). R0 resection was achieved in 92.5 % in the group L and in 95.0 % in the group S (p = 1.000). The 5-year overall survival and recurrence-free survival were better for group S than for group L (47.3 vs. 35.4 %, p = 0.044 and 27.3 vs. 14.9 %, p = 0.042, respectively). Multivariate analysis identified positive surgical margins and synchronous presentation as prognostic factors.

CONCLUSION

Since LLR was performed safely with favorable oncological adequacy in selected patients with large CRLMs, tumor size should not modify the surgical approach.

Liver Exposure Using Sterile Glove Pouch During Laparoscopic Right Liver Surgery in Hepatocellular Carcinoma Patients

BACKGROUND

Although laparoscopy is widely accepted for liver resection, lesions in the posterior and superior segments and deep region in the right lobe are difficult for visualization during laparoscopic liver resection (LLR). In this study, we aim examine the effects of using sterile gloves (SG) pouch padding during LLR.

METHODS

Forty-two hepatocellular carcinoma (HCC) patients were included in our study. We performed LLR using SG (n = 24, SG group) and without SG during LLR (n = 18, NSG). We also compared the time of various procedures, blood loss, and liver function between the two groups.

RESULTS

We did not observe any major complications or death in all patients. The time of liver parenchyma transection and portal triad clamping in SG group is significantly shorter than those in NSG group (30.29 ± 5.55 vs. 39.00 ± 3.68 min p < .001 for liver parenchyma transection, 23.00 ± 5.60 vs. 31.60 ± 5.03 min p < .001 for portal triad clamping). Blood loss in SG group (162.91 ± 90.91 ml) was significantly lower than in NSG group (236.66 ± 101.67 ml p = .024). The levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were increased one day after LLR, and decreased to normal level on day 7 after LLR in both groups.

CONCLUSIONS

Our data suggests that a sterile glove pouch could enhance exposure in surgical field, which results in decrease in blood loss and procedure time. More studies with large sample size, large tumor size, and longer follow-up are needed.

Application of stapling devices in liver surgery: Current status and future prospects

The liver is a vascular-rich solid organ. Safe and effective dissection of the vessels and liver parenchyma, and control of intraoperative bleeding are the main concerns when performing liver resection. Several studies have confirmed that intraoperative blood loss and postoperative transfusion are predictors of postoperative morbidity and mortality in liver surgery. Various methods and instruments have been developed during hepatectomy. Stapling devices are crucial for safe and rapid anastomosis. They are used to divide hepatic veins and portal branches, and to transect liver parenchyma in open liver resection. In recent years, laparoscopic liver surgery has developed rapidly, and is now preferred by many surgeons. Stapling devices have also been gradually introduced in laparoscopic liver surgery, from dividing vascular and biliary structures to parenchymal transection. This may be because staplers make manipulation more simple, rapid and safe. Even in single incision laparoscopic surgery, which is recognized as a new minimally invasive technique, staplers are also utilized, especially in left lateral hepatectomy. For safe application of stapling devices in liver surgery, more related designs and modifications, such as application of a suitable laparoscopic articulating liver tissue crushing device, a staple line reinforcement technique with the absorbable polymer membrane or radiofrequency ablation assistance, are still needed. More randomized studies are needed to demonstrate the benefits and find broader indications for the use of stapling devices, to help expand their application in liver surgery.

Blood transfusion is an independent predictor of morbidity and mortality after hepatectomy

BACKGROUND

Previous studies have indicated that blood transfusion is associated with increased risk of worse outcomes among patients selected for hepatectomy. However, the independent effect of transfusion has not been confirmed. We hypothesize that blood transfusion is an independent factor that affects outcomes in patients undergoing hepatectomy.

MATERIALS AND METHODS

Patients at tertiary care center who underwent hepatectomy between 2006 and 2013 were identified and linked with the American College of Surgeons National Surgical Quality Improvement Program PUF data set. Multivariable logistic regression analysis was used to estimate the effect of blood transfusion on 30-d mortality and morbidity, adjusted for differences in extent of resection and estimated probabilities of morbidity and mortality.

RESULTS

Among 522 patients in the study, 48 (9.2%) patients required perioperative blood transfusion within 72 h of resection, and 172 (33%) underwent major hepatectomy. Indications for hepatectomy included metastatic neoplasm (n = 229, 44%), primary hepatic neoplasm (n = 108, 21%), primary extra-hepatic biliary neoplasm (n = 23, 4%), and nonmalignant indications (n = 162, 31%). Eighty-eight (17%) patients had a postoperative morbidity. Blood transfusion was significantly associated with postoperative morbidity (odds ratio [OR] = 4.18, 95% CI = 2.18-8.02, P = 0.0001) and mortality (OR = 14.5, 95% CI = 3.08-67.8, P = 001), after adjustment for the concurrent effect of National Surgical Quality Improvement Program estimated probability of morbidity (OR = 1.15, 95% CI = 0.11-12.2, P = 0.042). The extent of resection was not significantly associated with morbidity (OR = 1.30, 95% CI, 0.74-2.28, P = 0.366) or mortality (OR = 1.14, 95% CI = 0.24-5.50, P = 0.870).

CONCLUSIONS

Blood transfusion is a highly statistically significant independent predictor of morbidity and mortality after hepatectomy. Judicious use of perioperative transfusion is indicated in patients with benign and malignant indications for liver resection.

Current status and future perspective of laparoscopic surgery in hepatobiliary disease

Recent advances in minimally invasive surgery include laparoscopic and robotic surgery. These surgical techniques have changed the paradigm of surgical treatment for hepatobiliary diseases. Minimally invasive surgery has the advantages of minimal wound extension for cosmetic effect, early postoperative recovery, and few postoperative complications in patients. For laparoscopic liver resection, the indications have been expanded and oncological outcome was proven to be similar with open surgery in the malignant disease. Laparoscopic cholecystectomy is a classical operation for benign gallbladder diseases and the effort to decrease the surgical wound resulted to perform single incision laparoscopic cholecystectomy. For choledochal cyst, laparoscopic surgery is applied gradually despite of the difficulties associated with anastomosis, and robotic surgery for hepatobiliary disease is also performed for more minimally invasive surgery; however, while admitting the advantage of robotic surgery, robotic technology should be improved for development of more convenient and cheaper instrument and continuous efforts to enhance surgical technique to overcome long operation is necessary. In this review, the status and future perspectives of minimally invasive surgery for hepatobiliary diseases are summarized and discussed.

Laparoscopic Right Hepatectomy by the Caudal Approach Versus Conventional Approach: A Comparative Study

BACKGROUND

Laparoscopic right hepatectomy (LRH) is increasingly performed for the treatment of many liver diseases. However, it remains a challenging procedure and is limited to highly specialized centers. Increasing the safety and efficacy of LRH is crucial. This study evaluated the safety and feasibility of the novel caudal approach (CDA) in LRH and in comparison with the conventional approach (CA).

METHODS

Of a total of 40 patients who underwent LRH between June 2007 and July 2015 at our center, 10 cases underwent the CDA, while 30 underwent the CA. Operative and postoperative outcomes were analyzed.

RESULTS

Clinical data and patient characteristics were comparable between the two groups. Only 1 patient required a laparoscopic-assisted procedure in the CDA group, while 14 patients were converted to laparotomy (n = 10) or laparoscopic-assisted procedures (n = 4) in the CA group, although the difference did not reach statistical significance (P = .060). However, the difference in conversion to laparotomy between the two groups was significant (P = .043). In addition, when considering 23 patients with malignancies, the median surgical margin was significantly greater in the CDA group (n = 6) (20 mm versus 10 mm; P = .023) than in the CA group (n = 17). Other operative and postoperative outcomes were similar between the two groups.

CONCLUSIONS

The CDA achieves safety and feasibility similar to that of the CA in LRH and requires relatively less conversion to laparotomy. In selected patients, the CDA offers an alternative option to the CA for LRH in experienced hands. Further studies with larger samples are warranted to evaluate the CDA.

Laparoscopic resection of a hepatic mucinous cystic neoplasm: A case report

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The first report of a hepatic mucinous cystic neoplasm (MCN-H) completely resected by laparoscopy.

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MCN-H has been reported to have the potential for malignancy, and recommended to resection.

•

Benign liver lesions including MCN-H are commonly observed in young females and lacparoscopic liver resection might have cosmetic advantages for patients.

Introduction

We aimed to present a case of hepatic mucinous cystic neoplasm (MCN-H) that was completely resected by laparoscopy.

Presentation of case

A 47-year-old female exhibited mild elevation of serum liver enzyme levels. Abdominal computed tomography revealed a 45-mm multilocular cystic tumor in segment IV of the liver, along with intermittent border calcification and minimal wall thickness. Magnetic resonance imaging revealed fluid-to-fluid level in the cystic tumor, thereby increasing the suspicion of a mild hemorrhage. The patient underwent laparoscopic liver resection (LLR) with a diagnosis of suspected mucinous cystic neoplasm of the liver. The entire tumor was successfully resected with a laparoscopic approach. The resected specimen was a 4.2 × 3.3 × 2.2-cm cystic tumor. Histological findings revealed mucin-producing singular epithelium and ovarian-like stroma. The tumor was diagnosed as a MCN-H with no malignancy.

Discussion

This is the first report in which a MCN-H was completely resected by laparoscopy. MCN-H is rare and is observed in only <5% of liver cystic tumors. MCN-H has been reported to have the malignant potential. And complete resection might be a good treatment option. Along with technical development, LLR has been indicated for benign liver tumors to date. Benign liver tumors are commonly observed in young females. The smaller incisions of the laparoscopic approach might provide cosmetic advantages for patients.

Conclusion

We presented the first case of a MCN-H completely resected by laparoscopy. Benign tumors and tumors with malignant potential might be good indications for a laparoscopic surgery.

Is the classification of intraoperative complications (CLASSIC) related to postoperative course?

INTRODUCTION

The Classification of Intraoperative Complications (CLASSIC) is one of two recent classification systems for intraoperative adverse events (iAEs), featuring simple but inclusive definitions. No data have been reported regarding the relation between CLASSIC and postoperative course. The aim of the present study was to evaluate the relation between the grade of iAEs and the grade of postoperative complications in patients who underwent hepatopancreaticobiliary (HPB) surgery.

METHODS

Demography, preoperative laboratory parameters, iAEs, postoperative complications, and intraoperative pH and lactate levels of patients who underwent HPB surgery between December 2014 and December 2015 were evaluated retrospectively. The recorded parameters were compared according to the grade of iAEs and the grade of postoperative complications described in the Accordion Severity Classification of Postoperative Complications.

RESULTS

Fifty-eight patients were considered. Mean age was 56 ± 15, 21 female vs. 37 male, 47 malign vs. 11 benign. Demographic features and preoperative status of the patients, and the presence of intraoperative acidosis were not significantly related to the grade of iAEs or postoperative complications. The grade of iAEs was directly proportional to the grade of postoperative complications (p = 0.031). Although it is not statistically significant, lactate level at the end of operation had a potential to predict the postoperative course (p = 0.057).

CONCLUSIONS

The grade of iAEs has a predictive value for the grade of postoperative complications in HPB surgery patients; hence, high grade of iAEs is significantly related to high grade of postoperative complications. Lactate level at the end of operation has the potential to predict the postoperative course.

Propensity score analysis of outcomes following laparoscopic or open liver resection for hepatocellular carcinoma

BACKGROUND

Liver resection is a potentially curative approach for hepatocellular carcinoma (HCC). Laparoscopic liver resections may reduce complication rates, especially in patients with cirrhosis. The aim of this study was to compare the results of laparoscopic liver resection with those of open liver resection for HCC.

METHODS

Patients with cirrhosis who underwent minor liver resections for HCC from 2006 to 2013 were identified retrospectively from a prospective database according to the technique adopted (laparoscopic or open). Short- and long-term outcomes were compared between the two groups before and after 1 : 1 propensity score matching.

RESULTS

A total of 269 patients were considered: 226 who underwent open liver resection and 43 who had a laparoscopic procedure. The two groups differed at baseline in terms of median age, sex, performance status, tumour location and type of resection. After propensity score matching, two comparable groups of 43 patients each were obtained. Intraoperative bleeding, margin clearance and operative mortality were similar in the two groups, whereas complication rates were lower (49 versus 19 per cent in open versus laparoscopic groups respectively; P = 0·004) and median hospital stay was shorter (8 versus 5 days; P < 0·001) in the laparoscopic group. On multivariable logistic regression analysis, the only independent factor that reduced the risk of postoperative complications was the use of laparoscopy (odds ratio 0·12, 95 per cent c.i. 0·03 to 0·55; P = 0·006). Median overall survival was 57·8 months in the open group and 48·8 months in the laparoscopic group (P = 0·802). Median disease-free survival was 31·7 and 25·5 months respectively (P = 0·990).

CONCLUSION

In comparison with the open approach, laparoscopic minor liver resections for HCC improved short-term outcomes, with similar survival results.

Feasibility of laparoscopic liver resection for caudate lobe: technical strategy and comparative analysis with anteroinferior and posterosuperior segments

BACKGROUND

Although laparoscopic liver resection (LLR) is now considered a standard procedure in peripheral segments, there are few reports on laparoscopic segment 1 (Sg1) resection. The aim of this study was to assess both safety and feasibility of Sg1 LLR.

METHODS

From 2000 to 2014, all patients who underwent LLR were identified from a prospective database. Patients with resection of Sg1 (Sg1 group) were compared with those with resection of anteroinferior segments (AI group: segments 3, 4b, 5, 6) or posterosuperior segments (PS group: segments 4a, 7, 8), in terms of tumor characteristics, surgical treatment, and short-term outcomes.

RESULTS

There were 15, 151, and 67 patients in Sg1, AI, and PS groups. Tumor size and tumor number were similar between the three groups (p = 0.139, p = 0.102). Operative time was significantly shorter in Sg1 (150 min) and AI group (135 min) compared with PS group (180 min) (p = 0.021). Median blood loss was notably higher in PS group (140 ml) compared with Sg1 group (75 ml) and AI group (10 ml) (p = 0.001). No mortality was observed in all groups. Postoperative complication rate was 20.0 % with Sg1 group, 14.6 % with AI group, and 20.9 % with PS group (p = 0.060). The rate of major complication was significantly higher in Sg1 group (13.3 %) and PS group (11.9 %) compared with AI group (4.0 %) (p = 0.042). Resection margins were clear in all Sg1 and PS group patients, whereas two (1.3 %) patients in AI group had R1 margins (p = 0.586).

CONCLUSION

The laparoscopic approach of isolated resection located in the caudate lobe is a feasible and curative surgical option in selected patients.

Minimally Invasive Surgery of the Liver

Operations on the liver have been undertaken for centuries for numerous indications including trauma, infections, and even for malignancy, but it was not until the past few decades that rates dramatically increased. This expanse in liver operations is due to a multitude of factors, including broader indications as well as improved safety. Our understanding of metastatic disease to the liver, especially colorectal cancer metastases, has vastly amplified the number of patients who would be candidates for hepatic resections and liver-directed therapies. We will focus our discussion here on planned minimally invasive operations for benign and malignant tumors as the majority of the literature relates to this setting.

Laparoscopic two-stage hepatectomy for bilobar colorectal liver metastases

Background

Despite the gradual diffusion of laparoscopic liver resection, the feasibility and results of laparoscopic two-stage hepatectomy (TSH) for bilobar colorectal liver metastases (CRLM) have not been described frequently. This study aimed to evaluate the feasibility, safety and oncological outcomes of laparoscopic TSH for bilobar CRLM.

Methods

All patients eligible for laparoscopic TSH among those treated for bilobar CRLM from 2000 to 2013 were included. Demographics, tumour characteristics, surgical procedures, and short- and long-term outcomes were analysed.

Results

Laparoscopic TSH was planned in 34 patients with bilobar CRLM, representing 17·2 per cent of all 198 patients treated for bilobar CRLM. Thirty patients received preoperative chemotherapy, and 20 had portal vein occlusion to increase the volume of the remnant liver. Laparoscopic resection of the primary colorectal tumour was integrated within the first-stage hepatectomy in 11 patients. After a median interval of 3·1 months, 26 patients subsequently had a successful laparoscopic second-stage hepatectomy, including 18 laparoscopic right or extended right hepatectomies. The mortality rate for both stages was 3 per cent (1 of 34), and the overall morbidity rate for the first and second stages was 50 per cent (17 of 34) and 54 per cent (14 of 26) respectively. Mean length of hospital stay was 6·1 and 9·0 days respectively. With a median follow-up of 37·8 (range 6–129) months, 3- and 5-year overall survival rates in patients who completed TSH were 78 and 41 per cent respectively. The 3- and 5-year disease-free survival rates were 26 and 13 per cent respectively.

Conclusion

Laparoscopic TSH for bilobar CRLM is safe and does not jeopardize long-term outcomes in selected patients.

Intermittent Pringle maneuver versus continuous hemihepatic vascular inflow occlusion using extra-glissonian approach in laparoscopic liver resection

BACKGROUND

Despite accumulated experience and advancing techniques for laparoscopic hepatectomy, bleeding remains the major concern during parenchymal transection. The vascular inflow control technique is still important to decrease intraoperative blood loss. The objective of this study was to compare intermittent Pringle with continuous hemihepatic vascular inflow occlusion using extra-glissonian approach in laparoscopic liver resection.

METHODS

Between January 2011 and January 2015, a total of 79 consecutive patients with tumors locating either in the right or in the left hemiliver were included into this retrospective study (45 in the Pringle group vs. 34 in the half-Pringle group). Preoperative clinical characteristics, intraoperative details, postoperative complications and outcomes of patients were compared.

RESULTS

The two groups were well matched according to clinical characteristics, tumor features, types of liver resection and histopathology (P > 0.05). The mean operative time (247.5 ± 61.3 vs. 221.4 ± 48.7 min, P = 0.0446), ischemic duration (62.8 ± 28.3 vs. 44.1 ± 20.5 min, P = 0.0017) and overall declamping time (21.2 ± 8.2 vs. 0.9 ± 1.9 min, P < 0.05) were significantly longer in the Pringle group than in the half-Pringle group. The mean amount of intraoperative blood loss (568.2 ± 325.1 vs. 420.7 ± 307.2 mL, P = 0.0444) and transfusion (266.1 ± 123.4 vs. 203.2 ± 144.6 mL, P = 0.0406) were significantly greater in the Pringle group. The overall operative morbidity rate was significantly higher in the Pringle group (40 vs. 17.6%, P = 0.0324). The Pringle group was associated with significantly higher alanine aminotransferase and aspartate transaminase levels on postoperative day (POD) 7 and lower albumin levels on PODs 1 and 3 (P < 0.05). The C-reactive protein levels were significantly higher in the Pringle group than in the half-Pringle group on POD 1 (37.5 ± 21.4 vs. 28.2 ± 19.0 mg/L, P = 0.0484), POD 3 (114.0 ± 53.4 vs. 90.6 ± 47.9 mg/L, P = 0.0474) and POD 7 (54.9 ± 29.8 vs. 40.1 ± 26.4 mg/L, P = 0.0245).

CONCLUSION

Continuous hemihepatic vascular inflow occlusion using extra-glissonian approach offers the advantages of less operative time and blood loss, less injury and better recovery in laparoscopic liver resection.