Laparoscopic Versus Open Right Posterior Sectionectomy for Hepatocellular Carcinoma in a High-Volume Center: A Propensity Score Matched Analysis. World J Surg. 2018;42:2930-2937. [PMID: 29426971 DOI: 10.1007/s00268-018-4531-z]

Low versus standard central venous pressure during laparoscopic liver resection: A systematic review, meta-analysis and trial sequential analysis

To compare the outcomes of low central venous pressure (CVP) to standard CVP during laparoscopic liver resection. The study design was a systematic review following the PRISMA statement standards. The available literature was searched to identify all studies comparing low CVP with standard CVP in patients undergoing laparoscopic liver resection. The outcomes included intraoperative blood loss (primary outcome), need for blood transfusion, mean arterial pressure, operative time, Pringle time, and total complications. Random- effects modelling was applied for analyses. Type I and type II errors were assessed by trial sequential analysis (TSA). A total of 8 studies including 682 patients were included (low CVP group, 342; standard CVP group, 340). Low CVP reduced intraoperative blood loss during laparoscopic liver resection (mean difference [MD], -193.49 mL; 95% confidence interval [CI], -339.86 to -47.12; p = 0.01). However, low CVP did not have any effect on blood transfusion requirement (odds ratio [OR], 0.54; 95% CI, 0.28-1.03; p = 0.06), mean arterial pressure (MD, -1.55 mm Hg; 95% CI, -3.85-0.75; p = 0.19), Pringle time (MD, -0.99 minutes; 95% CI, -5.82-3.84; p = 0.69), operative time (MD, -16.38 minutes; 95% CI, -36.68-3.39; p = 0.11), or total complications (OR, 1.92; 95% CI, 0.97-3.80; p = 0.06). TSA suggested that the meta-analysis for the primary outcome was not subject to type I or II errors. Low CVP may reduce intraoperative blood loss during laparoscopic liver resection (moderate certainty); however, this may not translate into shorter operative time, shorter Pringle time, or less need for blood transfusion. Randomized controlled trials with larger sample sizes will provide more robust evidence.

Goal-directed fluid therapy during post-resection phase in low central venous pressure assisted laparoscopic hepatectomy: a randomized controlled superiority trial

PURPOSE

The purpose of this prospective single blinded randomized controlled trial was to find out whether goal-directed fluid therapy (GDFT) strategy in post-transection period in low central venous pressure (CVP) assisted laparoscopic hepatectomy (LH) has more benefit than traditional fluid strategy.

METHODS

Between April 2020 and Dec 2021, patients who were scheduled for laparoscopic liver resection surgery were eligible to participate in the study. Patients were randomly divided into two groups: control group that received traditional fluid strategy in post-transection period in low CVP assisted laparoscopic hepatectomy and GDFT strategy group that received GDFT strategy in post-transection period. The primary outcome parameter is the incidence of postoperative complications. Secondary outcome parameters include perioperative clinical outcomes, postoperative clinical outcomes, length of hospital stay after surgery, postoperative lactic acid, fluids and vasoactive medications during the operation.

RESULTS

A total of 159 patients in the control group and 160 patients in the GDFT were included. Two groups had no significant difference in the incidence of postoperative complications including pneumonia (P = 0.34), acute kidney injury (P = 0.72), hepatic insufficiency (P = 0.25), pleural effusion (P = 0.08) and seroperitoneum (P = 1.00), respectively. The amount of perioperative urine output is fewer in GDFT group than in the control group (P = 0.0354), while other perioperative variables and postoperative variables were comparable between two groups.

CONCLUSIONS

The results show the implementation of GDFT strategy is not associated with fewer postoperative complications. GDFT strategy did not result in improved outcomes in low CVP-assisted laparoscopic hepatectomy.

Laparoscopic versus open in right posterior sectionectomy: a systematic review and meta-analysis

BACKGROUND

Laparoscopic liver resection (LLR) is now widely adopted for the treatment of liver tumors due to its minimally invasive advantages. However, multicenter, large-sample population-based laparoscopic right posterior sectionectomy (LRPS) has rarely been reported. We aimed to assess the advantages and drawbacks of right posterior sectionectomy compared with laparoscopic and open surgery by meta-analysis.

METHODS

Relevant literature was searched using the PubMed, Embase, Cochrane, Ovid Medline, and Web of Science databases up to September 12, 2021. Quality assessment was performed based on a modified version of the Newcastle-Ottawa Scale (NOS). The data were analyzed by Review Manager 5.3. The data were calculated by odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CI) for fixed-effects and random-effects models.

RESULTS

The meta-analysis included seven studies involving 739 patients. Compared with open right posterior sectionectomy (ORPS), the LRPS group had lower intraoperative blood loss (MD - 135.45; 95%CI - 170.61 to - 100.30; P < 0.00001) and shorter postoperative hospital stays (MD - 2.17; 95% CI - 3.03 to - 1.31; P < 0.00001). However, there were no statistically significant differences between LRPS and ORPS regarding operative time (MD 44.97; P = 0.11), pedicle clamping (OR 0.65; P = 0.44), clamping time (MD 2.72; P = 0.31), transfusion rate (OR 1.95; P = 0.25), tumor size (MD - 0.16; P = 0.13), resection margin (MD 0.08; P = 0.63), R0 resection (OR 1.49; P = 0.35), recurrence rate (OR 2.06; P = 0.20), 5-year overall survival (OR 1.44; P = 0.45), and 5-year disease-free survival (OR 1.07; P = 0.88). Furthermore, no significant difference was observed in terms of postoperative complications (P = 0.08), bile leakage (P = 0.60), ascites (P = 0.08), incisional infection (P = 0.09), postoperative bleeding (P = 0.56), and pleural effusion (P = 0.77).

CONCLUSIONS

LRPS has an advantage in the length of hospital stay and blood loss. LRPS is a very useful technology and feasible choice in patients with the right posterior hepatic lobe tumor.

Positioning of Minimally Invasive Liver Surgery for Hepatocellular Carcinoma: From Laparoscopic to Robot-Assisted Liver Resection

Laparoscopic liver resection (LLR) is widely accepted in the surgical treatment of hepatocellular carcinoma (HCC) through international consensus conferences and the development of difficulty classifications. LLR has been reported to result in earlier postoperative recovery and fewer postoperative complications than open liver resection (OLR) for HCC. However, the prevalence of liver cirrhosis, obesity, the elderly, HCC recurrence (repeat liver resection), and major resection must be considered for LLR for HCC. Some systematic reviews, meta-analysis studies, and large cohort studies indicated that LLR is technically feasible for selected patients with HCC with these factors that led to less intraoperative blood loss, fewer transfusions and postoperative complication incidences, and shorter hospital stays than OLR. Furthermore, some reported LLR prevents postoperative loss of independence. No difference was reported in long-term outcomes among patients with HCC who underwent LLR and OLR; however, some recent reports indicated better long-term outcomes with LLR. In recent years, robot-assisted liver resection (RALR) has gradually become popular, and its short- and long-term results for HCC are not different from those of LLR. Additionally, RALR is expected to become the mainstay of minimally invasive surgery in the future.

Caudodorsal approach combined with in situ split for laparoscopic right posterior sectionectomy

BACKGROUND

Laparoscopic right posterior sectionectomy (LRPS) was technically challenging and lack of standardization. There were some approaches for LRPS, such as caudal approach and dorsal approach. During our practice, we initiated pure LRPS using the caudodorsal approach with in situ split and present several advantages of this method.

METHODS

From April 2018 to December 2021, consecutive patients who underwent pure LRPS using the caudodorsal approach with in situ split at our institution entered into this retrospective study. The key point of the caudodorsal approach was that the right hepatic vein was exposed from peripheral branches toward the root and the parenchyma was transected from the dorsal side to ventral side. Specially, the right perihepatic ligaments were not divided to keep the right liver in situ before parenchymal dissection for each case.

RESULTS

11 patients underwent pure LRPS using the caudodorsal approach with in situ split. There were 9 hepatocellular carcinoma, 1 sarcomatoid hepatocellular carcinoma, and 1 hepatic hemangioma. Five patients had mild cirrhosis and 1 had moderate cirrhosis. All the procedures were successfully completed laparoscopically. The median operative time was 375 min (range of 290-505 min) and the median blood loss was 300 ml (range of 100-1000 ml). Five patients received perioperative blood transfusion, of which 1 patient received autologous blood transfusion and 2 patients received blood transfusion due to preoperative moderate anemia. No procedure was converted to open surgery. Two patients who suffered from postoperative complications, improved after conservative treatments. The median postoperative stay was 11 days (range of 7-25 days). No postoperative bleeding, hepatic failure, and mortality occurred.

CONCLUSION

The preliminary clinical effect of the caudodorsal approach with in situ split for LRPS was satisfactory. Our method was feasible and expected to provide ideas for the standardization of LRPS. Further researches are required due to some limitations of this study.

Utility of the Iwate difficulty scoring system for laparoscopic right posterior sectionectomy: do surgical outcomes differ for tumors in segments VI and VII?

INTRODUCTION

The Iwate Score (IS) have not been well-validated for specific procedures, especially for right posterior sectionectomy (RPS). In this study, the utility of the IS was determined for laparoscopic (L)RPS and the effect of tumor location on surgical outcomes was investigated.

METHODS

Post-hoc analysis of 647 L-RPS performed in 40 international centers of which 596L-RPS cases met the inclusion criteria. Baseline characteristics and perioperative outcomes of patients stratified based on the Iwate score were compared to determine whether a correlation with surgical difficulty existed. A 1:1 Mahalanobis distance matching was utilized to investigate the effect of tumor location on L-RPS outcomes.

RESULTS

The patients were stratified into 3 levels of difficulty (31 intermediate, 143 advanced, and 422 expert) based on the IS. When using a stepwise increase of the IS excluding the tumor location score, only Pringle's maneuver was more frequently used in the higher surgical difficulty level (35.5%, 54.6%, and 65.2%, intermediate, advanced, and expert levels, respectively, Z = 3.34, p = 0.001). Other perioperative results were not associated with a statistical gradation toward higher difficulty level. 80 of 85 patients with a segment VI lesion and 511 patients with a segment VII lesion were matched 1:1. There were no significant differences in the perioperative outcomes of the two groups including open conversion, operating time, blood loss, intraoperative blood transfusion, postoperative stay, major morbidity, and mortality.

CONCLUSION

Among patients undergoing L-RPS, the IS did not significantly correlate with most outcome measures associated with intraoperative difficulty and postoperative outcomes. Similarly, tumor location had no effect on L-RPS outcomes.

The safety and feasibility of laparoscopic right posterior sectionectomy vs. open approach: A systematic review and meta-analysis

Background

Laparoscopic right posterior sectionectomy (LRPS) is one of the most technically challenging and potentially hazardous procedures in laparoscopic liver resection. Although some available literature works demonstrated the safety and feasibility of LRPS, these data are limited to reports from a single institution and a small sample size without support from evidence-based medicine. So, we performed a meta-analysis to assess further the safety and feasibility of LRPS by comparing it with open right posterior sectionectomy (ORPS).

Methods

MEDLINE, Embase, and Cochrane Library were systematically searched for eligible studies comparing LRPS and open approaches. Random and fixed-effects models were used to calculate outcome measures.

Results

Four studies involving a total of 541 patients were identified for inclusion: 250 in the LRPS group and 291 in the ORPS group. The postoperative complication and margin were not statistically different between the two groups (OR: 0.49, 95% CI: 0.18 to 1.35, P = 0.17) (MD: 0.05, 95% CI: −0.47 to 0.57, P = 0.86), respectively. LRPS had a significantly longer operative time and shorter hospital stay (MD: 140.32, 95% CI: 16.73 to 263.91, P = 0.03) (MD: −1.64, 95% CI: −2.56 to −0.72, P = 0.0005) respectively.

Conclusion

Data from currently available literature suggest that LRPS performed by an experienced surgeon is a safe and feasible procedure in selected patients and is associated with a reduction in the hospital stay.

Minimally Invasive vs Open Major Hepatectomies for Liver Malignancies: a Propensity Score-Matched Analysis

BACKGROUND

The majority of evidence with regards to minimally invasive liver resection (MILR) favors its application in minor hepatectomies. We conducted a propensity score-matched (PSM) analysis to determine its feasibility and safety in major hepatectomies (MIMH) for liver malignancies.

METHODS

Retrospective review of 130 patients who underwent MIMH and 490 patients who underwent open major hepatectomy (OMH) for malignant pathologies was performed. PSM in a 1:1 ratio identified two groups of patients with similar baseline clinicopathological characteristics. Perioperative outcomes were then compared. Major hepatectomies included traditional major (>3 segments) and technical major hepatectomies (right anterior and right posterior sectionectomies).

RESULTS

Both cohorts were well-matched for baseline characteristics after PSM. Of 130 MIMH cases, there were 12 conversions to open. Comparison of perioperative outcomes demonstrated a significant association of MIMH with longer operation time and more frequent application of Pringle's maneuver (PM), but decreased postoperative stay. These results were consistent on a subgroup analysis that only included patients undergoing traditional major hepatectomies. A second subgroup analysis restricted to cirrhotic patients demonstrated that while perioperative outcomes were equivalent, MIMH was similarly associated with a longer operative time. Subset analyses of resections performed after 2015 demonstrated that MIMH was additionally associated with a lower postoperative morbidity compared to OMH.

CONCLUSION

Comparison of perioperative and short-term oncological outcomes between MIMH and OMH for malignancies demonstrated that MIMH is feasible and safe. It is associated with a shorter hospital stay at the expense of a longer operation time compared to OMH.

Laparoscopic versus open repeat liver resection for recurrent hepatocellular carcinoma in hepatectomy patients: inverse probability of treatment weighting

Repeat liver resection (RLR) is a good treatment option for recurrent hepatocellular carcinoma (HCC). However, laparoscopic repeat liver resection (LRLR) is more technically demanding than open repeat liver resection (ORLR). The purpose of our study is to compare the surgical outcomes of ORLR and LRLR and to carefully present LRLR guidelines for HCC. We performed RLR at a single institution from January 2017 to November 2019. We divided the patients into an ORLR group and an LRLR group. Inverse probability of treatment weighting (IPTW) was applied in this study to compare the ORLR group and the LRLR group. There was no difference between the two groups in patient characteristics, preoperative blood tests and pathological characteristics. After stabilized IPTW, the LRLR group had a shorter hospital stay (5.52 vs. 9.27 days, p = 0.001) and superior disease-free survival (p = 0.020). LRLR yielded better short-term outcomes than ORLR. And if a regular radiologic examination is performed, most of the recurrent tumors could be detected less than 3 cm. In conclusion, LRLR might be feasible and useful for recurrent HCC located contralateral to the previous tumor at a size of less than 3 cm.

Current status of laparoscopic hepatectomy for the treatment of hepatocellular carcinoma: A systematic literature review

BACKGROUND

Laparoscopic hepatectomy (LH) was first introduced in the 1990s and has now become widely accepted for the treatment of hepatocellular carcinoma (HCC). Laparoscopic liver resection (LLR) is considered a safe and effective approach for liver disease. However, the role of laparoscopic hepatectomy in HCC with cirrhosis remains controversial and needs to be further assessed, and the present literature review aimed to review the surgical and oncological outcomes of Laparoscopic hepatectomy (LH). According to Hong and colleagues laparoscopic resection for liver cirrhosis is a very safe and feasible procedure for both ideal cases and select patients with high risk factors [29]. The presence of only 1 of these factors does not represent an absolute contraindication for LH.

METHODS AND RESULTS

We selected 23 studies involving about 1363 HCC patients treated with LH. 364 (27%) patients experienced major resections. The mean operative time was 244.9 minutes, the mean blood loss was 308.1 mL and blood transfusions were required in only 4.9% of patients. There were only 2 (0.21%) postoperative deaths and overall morbidity was 9.9%. Tumor recurrence ranged from 6 to 25 months. The 1-year, 3-year, and 5-year disease free Survival (DFS) rates ranged from 71.9% to 99%, 50.3% to 91.2%, and 19% to 82% respectively. Overall survival rates ranged from 88% to 100%, 73.4% to 94.5%, and 52.6% to 94.5% respectively.

CONCLUSIONS

In our summery LH is lower risk and safer than conventional open liver surgery and is just as efficacious. Also, the LH approach decreased blood-loss, operation time, postoperative morbidity and had a lower conversion rate compared to other procedures whether open or robotic. Finally, LH may serve as a promising alternative to open procedures.

Hand-Assisted Laparoscopic Surgery Is Superior to Open Liver Resection for Colorectal Liver Metastases in the Posterosuperior Segments

Introduction: Laparoscopic liver resections (LLR) of colorectal metastasis located in posterosuperior segments (1, 4A, 7 and 8) are challenging and highly demanding. The aim of our study is to determine the safety and feasibility of hand-assisted laparoscopic surgery (HALS) in the resections of the posterosuperior lesions and to compare the peri-operative, short-term and long-term outcomes with the open liver resection (OLR) approach.

Methods and Results: A retrospective study of patients who underwent either HALS or OLR for metastatic colorectal cancer (mCRC) located in the posterosuperior segments of the liver between 2008 and 2018 in two university affiliated medical centers.

Results: A total of 187 patients were identified, of whom 78 underwent HALS and 109 underwent OLR. There was no difference between the HALS and OLR with regard to preoperative factors (age, primary CRC tumor location, number and anatomical distribution of liver metastasis, pre-operative neo-adjuvant treatment, operative time, blood transfusion rate, and resection margins positivity). On the other hand, HALS compared to OLR had a significantly shorter mean hospital stay (4 vs. 6 days; P = 0.003), and a lower total complications rate (25 vs. 47% P = 0.006). Both groups had no 30-day mortality. Also, patients who underwent HALS vs. OLR had similar liver metastases recurrence (55 vs. 51%. P = 0.65) and 5-year survival (47 vs. 45%. P = 0.72).

Conclusions: HALS for mCRC located in posterosuperior liver segments is safe and feasible and it is a preferable approach due to its lower complication rate and shorter hospital stay while not compromising survival and disease recurrence.

Long-term survival outcome of laparoscopic liver resection for hepatocellular carcinoma

Long-term survival is the most important outcome measurement of a curative oncological treatment. For hepatocellular carcinoma (HCC), the long-term disease-free and overall survival of laparoscopic liver resection (LLR) is shown to be non-inferior to the current standard of open liver resection (OLR). Some studies have reported a superior long-term oncological outcome in LLR when compared to OLR. It has been argued that improvement of visualization and instrumentation and reduced operative blood loss and perioperative blood transfusion may contribute to reduced risk of postoperative tumor recurrence. On the other hand, since most of the comparative studies of the oncological outcomes of LLR and OLR for HCC are non-randomized, it remained inconclusive as to whether LLR confers additional survival benefit compared to OLR. Despite the paucity of level 1 evidence, the practice of LLR for HCC has gained wide-spread acceptance due to the reproducible improvements in the perioperative outcomes and non-inferior oncological outcomes demonstrated by large-scaled, matched comparative studies. Meta-analyses of the outcomes of these studies by multiple systematic reviews have also returned noncontradictory conclusions. On the basis of a theoretical advantage of LLR over OLR in preventing tumor recurrence, the current review aims to dissect from the current meta-analyses and comparative studies any evidence of such superiority.

Does minimally invasive liver resection improve long-term survival compared to open resection for hepatocellular carcinoma? A systematic review and meta-analysis

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.

Survival analysis between laparoscopic and open hepatectomy for hepatocellular carcinoma: a meta-analysis based on reconstructed time-to-event data

BACKGROUND/PURPOSE OF THE STUDY

Laparoscopic hepatectomy (LH) has been widely used in the treatment of hepatocellular carcinoma (HCC). It is generally believed that the long-term outcomes of LH are not inferior to open hepatectomy (OH). However, the quality of evidence is low. The purpose of this study was to reconstruct time-to-event data for meta-analysis based on Kaplan-Meier curves from propensity-score matched studies and compare survival rates following LH and OH for hepatocellular carcinoma.

METHODS

All published propensity-score matched studies reported in English that compared LH and OH for hepatocellular carcinoma with Kaplan-Meier curves were screened. Patients' survival information was reconstructed with the aid of a computer vision program. Different models (fixed-effects model for two-stage survival analysis and Cox regression for one-stage survival analysis) were performed for sensitivity analysis. In addition to the primary meta-analysis, two specific subgroup analyses were performed on patients by types of resection, cirrhosis status.

RESULTS

Time-to-event data were extracted from 45 propensity-score matched studies (N = 8905). According to the time-to-event data and the reconstructed Kaplan-Meier curves, the cumulative overall survival rate was 49.0% and 50.9% in the LH and OH cohorts, respectively, a log-rank test did not demonstrate statistical significance (p > 0.05). The cumulative recurrence-free survival (RFS) probability was both close to 0.0%. The median RFS time was 49.1 (95% CI 46.1 ~ 51.7) and 44.3 (95% CI 41 ~ 46.1) months. The difference in disease status was statistically significant by the Log-rank test (p < 0.05). Using the random-effects model of two-stage analysis, the minor hepatectomy subgroup (HR = 1.32, 95% CI [1.09, 1.55], I² = 6.2%, p = 0.383) and the shared fragile model of one-stage analysis (HR = 1.44 95% CI [1.23, 1.69], p < 0.001) suggested that LH could significantly prolong RFS of patients compared with OH. This result was consistent with sensitivity analysis using different models.

CONCLUSION

This study was the first reconstructed time-to-event data based on a high-quality propensity-score matching study to compare the survival outcomes of LH and OH in the treatment of HCC. Results suggested that LH can improve RFS in patients with HCC undergoing minor hepatectomy and may also benefit long-term RFS in overall patients.

Laparoscopic Living Donor Right Hepatectomy Regarding the Anatomical Variation of the Portal Vein: A Propensity Score-Matched Analysis

This study is designed to analyze the feasibility of laparoscopic living donor right hemihepatectomy in living donors with portal vein variation. Living donor liver transplantation cases using a right liver graft during the period of January 2014 to September 2019 were included. Computed tomographic angiographies of the donor were 3-dimensionally reconstructed, and the anatomical variation of the portal vein was classified. To reduce selection bias, a 1:1 ratio propensity score-matched analysis between the laparoscopy group and the open group was performed. Surgical and recovery-related outcomes as well as portal vein complication-free survival, graft survival, and overall survival rates were analyzed. After matching, 171 cases in each group from 444 original cases were compared. The laparoscopy group had a shorter operation time (P < 0.001), a smaller number of additional opioids required by the donor (P < 0.001), and a shorter hospital stay (P < 0.001). There were no differences in the portal vein complication-free survival (P = 0.16), graft survival (P = 0.26), or overall survival rates (P = 0.53). Although portal vein complication-free survival was inferior in portal veins other than type I (P = 0.01), the laparoscopy group showed similar portal vein complication-free survival regardless of the anatomical variation of portal vein (P = 0.35 in type I and P = 0.30 in other types). Laparoscopic living donor right hemihepatectomy can be performed as safely as open surgery regardless of the anatomical variation of the portal vein.

Laparoscopic versus open major liver resection for hepatocellular carcinoma: A case-matched analysis of short- and long-term outcomes

Background

The feasibility and safety of laparoscopic major hepatectomy (LMH) are still uncertain. The purpose of the present study is to compare the short- and long-term outcomes of LMH with those of open major hepatectomy (OMH) for hepatocellular carcinoma (HCC).

Method

Between January 2012 and December 2018, a total of 26 patients received laparoscopic major hepatectomy in our center. To minimize any confounding factors, a 1:3 case-matched analysis was conducted based on the demographics and extent of liver resection. Data of demographics, perioperative outcomes, and long-term oncologic outcomes were reviewed.

Results

Intraoperative blood loss (P = 0.007) was significantly lower in the LMH group. In addition, the LMH group exhibited a lower overall complication rate (P = 0.039) and shorter postoperative hospital stay (P = 0.024). However, no statistically significant difference was found between LMH and OMH regarding operation time (P = 0.215) and operative cost (P = 0.860). Two laparoscopic cases were converted to open liver resection. In regard to long-term outcomes, there was no significant difference between LMH and OMH regarding disease-free survival (DFS) (P = 0.079) and overall survival (OS) (P = 0.172).

Conclusion

LMH can be an effective and safe alternative to OMH for selected patients with liver cancer in short- and long-term outcomes.

Application of three-dimensional printing for intraoperative guidance during liver resection of a hepatocellular carcinoma with sophisticated location

While 3D printing is adapted usefully in certain field of surgery, its application in liver surgery was limited. Here, we introduce our experience for using 3D printing for intraoperative guidance during liver resection in a case for HCC with an intrahepatic metastasis at a sophisticated location. A 50 years old male patient was diagnosed 4.7 cm-sized hepatocellular carcinoma located on segment 3 with and an intrahepatic metastasis located on segment 8 which was between right anterior portal vein, middle hepatic vein and right hepatic vein. Since radiofrequency ablation appeared to be inappropriate, surgical resection was planned. However, the patient had a cirrhotic liver and left liver was estimated to be 47% according to volume measurement. Therefore, we planned a two-step procedure by performing left hemihepatectomy preserving the middle hepatic vein and additionally removing the intrahepatic metastasis by tumorectomy. For better guidance, we made a 3D printed model tailored for using it as a guidance during operation, and the accuracy of 3D-printed model helped the surgical team perform a safe operation. The patient underwent adjuvant proton beam therapy on the site of tumorectomy and did not experience recurrence.

Laparoscopic hepatectomy versus open hepatectomy for tumors located in right posterior segment: A single institution study

OBJECT

With the gradual advancement of laparoscopic technology, surgeries can be successfully performed with the help of laparoscopy increasingly. This study initially explored the difference between laparoscopic right posterior sectionectomy (LRPS) and open right posterior sectionectomy (ORPS)of liver in our center, discussed the effectiveness, benefits and safety of LRPS and introduce some surgical techniques in our center.

MATERIALS AND METHODS

We retrospectively analyze 96 cases of liver tumor located in the right posterior lobe of liver in our institution from January 2015 to January 2018. There were 46 cases performed the LRPS surgery and 50 cases performed the ORPS surgery. Through analysis of the perioperative outcomes of these two groups by a case control study, we compare the differences between these two groups.

RESULTS

There was no significant difference between the LRPS and ORPS group in demographic and baseline characteristics before surgery. Patients in the LRPS group were significantly superior to ORPS in terms of postoperative liver function recovery, postoperative inflammatory factor level, pain sensation (3.03 ± 0.79 vs 4.58 ± 1.25), abdominal incision length (6.25 ± 2.34 vs 32.15 ± 3.21), carrying abdominal drainage tube time (3.26 ± 0.77 vs 4.83 ± 0.76), recovery of bowel function time (1.6 ± 0.61 VS 3.05 ± 0.85)and postoperative hospital stay (5.73 ± 0.99 vs 7.16 ± 0.95) (P < 0.05).

CONCLUSION

Compared with the traditional ORPS, LRPS has the advantages of minor injury, faster recovery and mild inflammatory reaction. The LRPS is safe and feasible, and it should be gradually promoted in clinical practice.

Indocyanine green fluorescence imaging-guided laparoscopic right posterior hepatectomy

BACKGROUND

Laparoscopic right posterior hepatectomy is considered difficult on the basis of the surgery difficulty scoring system. In this study, we evaluated the safety and effectiveness of the technical application of indocyanine green (ICG) fluorescence imaging-guided laparoscopic right posterior hepatectomy.

METHODS

Twenty-six patients who underwent ICG fluorescence imaging-guided laparoscopic right posterior hepatectomy at Hepatobiliary and Pancreatic Surgery Department of Zhongnan Hospital, Wuhan University, from June 2018 to December 2019, were included. The influence of patient position, trocar placement, hepatic inflow occlusion, central venous pressure (CVP), and the ICG fluorescence imaging-guided method were analyzed.

RESULTS

In 17 patients, the left lateral position was maintained when the main tumor was in the S7, and in the remaining nine patients, the supine position was maintained with the right side of the body raised when the main tumor was in the S6. Ten patients who underwent preoperative injection of ICG were successfully developed for nonanatomical hepatectomy. Sixteen patients received intraoperative ICG injection for anatomical hepatectomy (2 cases had positive imaging findings, 14 cases had negative imaging findings, and 2 cases had failed imaging findings). All patients underwent the Pringle maneuver during the procedure. Four patients were preset with subhepatic vena cava blocking and one patient with suprahepatic inferior vena cava blocking. CVP was controlled at 3.00 ± 0.63 (mean ± SD) cmH₂O. The operative time was 216.14 ± 52.05 min, and the bleeding volume was 128.57 ± 75.55 ml. Four patients had Clavien-Dindo level I complications, and one had level III complications. Postoperative hospitalization duration was 6.19 ± 1.40 days. There were 14 patients with hepatocellular carcinoma, 9 with metastatic liver malignancies, 2 with hepatic hemangioma, 1 with focal nodular hyperplasia of the liver, and 10 with hepatitis B liver cirrhosis.

CONCLUSIONS

ICG fluorescence imaging guidance could be helpful for the safe implementation of laparoscopic right posterior hepatectomy.

Laparoscopic Versus Open Liver Resection for Tumors in the Posterosuperior Segments: A Systematic Review and Meta-analysis

OBJECTIVE

The objective of this study was to compare the outcomes of laparoscopic and open liver resection for tumors in the posterosuperior segments.

METHODS

We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. We conducted a search of electronic information sources to identify all studies comparing outcomes of laparoscopic and open liver resection for tumors in the posterosuperior segments. We used the Risk Of Bias In Nonrandomized Studies-of Interventions (ROBINS-I) tool to assess the risk of bias of the included studies. Fixed-effect or random-effects models were applied to calculate pooled outcome data.

RESULTS

We identified 11 observational studies, enrolling a total of 1023 patients. The included population in both groups were comparable in terms of baseline characteristics. Laparoscopic approach was associated with lower risks of total complications [odds ratio (OR): 0.45; 95% confidence interval (CI): 0.33, 0.61; P<0.00001], major complications (Dindo-Clavien III or more) (OR: 0.52; 95% CI: 0.36, 0.73; P=0.0002), and intraoperative blood loss [mean difference (MD): -114.71; 95% CI: -165.64, -63.79; P<0.0001]. Laparoscopic approach was associated with longer operative time (MD: 50.28; 95% CI: 22.29, 78.27; P=0.0004) and shorter length of hospital stay (MD: -2.01; 95% CI: -2.09, -1.92; P<0.00001) compared with open approach. There was no difference between the 2 groups in terms of need for blood transfusion (OR: 1.23; 95% CI: 0.75, 2.02; P=0.41), R0 resection (OR: 1.09; 95% CI: 0.66, 1.81; P=0.72), postoperative mortality (risk difference: -0.00; 95% CI: -0.02, 0.02; P=0.68), and need for readmission (OR: 0.70; 95% CI: 0.19, 2.60; P=0.60). In terms of oncological outcomes, there was no difference between the groups in terms disease recurrence (OR: 1.58; 95% CI: 0.95, 2.63; P=0.08), overall survival (OS) at maximum follow-up (OR: 1.09; 95% CI: 0.66, 1.81; P=0.73), 1-year OS (OR: 1.53; 95% CI: 0.48, 4.92; P=0.47), 3-year OS (OR: 1.26; 95% CI: 0.67, 2.37; P=0.48), 5-year OS (OR: 0.91; 95% CI: 0.41, 1.99; P=0.80), disease-free survival (DFS) at maximum follow-up (OR: 0.91; 95% CI: 0.65, 1.27; P=0.56), 1-year DFS (OR: 1.04; 95% CI: 0.60, 1.81; P=0.88), 3-year DFS (OR: 1.13; 95% CI: 0.75, 1.69; P=0.57), and 5-year DFS (OR: 0.73; 95% CI: 0.44, 1.24; P=0.25).

CONCLUSIONS

Compared with the open approach in liver resection for tumors in the posterosuperior segments, the laparoscopic approach seems to be associated with a lower risk of postoperative morbidity, less intraoperative blood loss, and shorter length of hospital stay with comparable survival and oncological outcomes. The best available evidence is derived from observational studies with moderate quality; therefore, high-quality randomized controlled trials with adequate statistical power are required to provide a more robust basis for definite conclusions.

The Safety and Feasibility of Laparoscopic Technology in Right Posterior Sectionectomy

BACKGROUND

Laparoscopic hepatectomy has been accepted widely due to its advantages as a minimally invasive surgery, but laparoscopic right posterior sectionectomy (LRPS) has rarely been reported. We aimed to explore the safety and feasibility of LRPS by comparing it with open surgical approaches.

MATERIALS AND METHODS

Between January 2014 and July 2019, 51 patients who underwent right posterior sectionectomy were enrolled in this study. The patients' characteristics, intraoperative details, and postoperative outcomes were compared between 2 groups.

RESULTS

There were no statistically significant differences in the preoperative data. LRPS showed significantly less blood loss (P=0.001) and shorter hospital stay (P=0.002) than open right posterior sectionectomy, but hospital expenses (P=0.382), operative time (P=0.196), surgical margin (P=0.311), the rate of other complications, and the postoperative white blood cell count, alanine aminotransferase, aspartate aminotransferase, and total bilirubin showed no statistically significant differences between the 2 groups (P>0.05). For hepatocellular carcinoma, the results showed there were no differences in both disease-free survival (P=0.220) and overall survival (P=0.417) between the 2 groups.

CONCLUSIONS

Our research suggests that LRPS is a safe and feasible surgical procedure that is efficient from an oncological point of view. It may be the preferred choice for lesions in the right posterior hepatic lobe.

Laparoscopic versus open right posterior sectionectomy: an international, multicenter, propensity score-matched evaluation

Background

Although laparoscopic liver resection has become the standard for minor resections, evidence is lacking for more complex resections such as the right posterior sectionectomy (RPS). We aimed to compare surgical outcomes between laparoscopic (LRPS) and open right posterior sectionectomy (ORPS).

Methods

An international multicenter retrospective study comparing patients undergoing LRPS or ORPS (January 2007—December 2018) was performed. Patients were matched based on propensity scores in a 1:1 ratio. Primary endpoint was major complication rate defined as Accordion ≥ 3 grade. Secondary endpoints included blood loss, length of hospital stay (LOS) and resection status. A sensitivity analysis was done excluding the first 10 LRPS patients of each center to correct for the learning curve. Additionally, possible risk factors were explored for operative time, blood loss and LOS.

Results

Overall, 399 patients were included from 9 centers from 6 European countries of which 150 LRPS could be matched to 150 ORPS. LRPS was associated with a shorter operative time [235 (195–285) vs. 247 min (195–315) p = 0.004], less blood loss [260 (188–400) vs. 400 mL (280–550) p = 0.009] and a shorter LOS [5 (4–7) vs. 8 days (6–10), p = 0.002]. Major complication rate [n = 8 (5.3%) vs. n = 9 (6.0%) p = 1.00] and R0 resection rate [144 (96.0%) vs. 141 (94.0%), p = 0.607] did not differ between LRPS and ORPS, respectively. The sensitivity analysis showed similar findings in the previous mentioned outcomes. In multivariable regression analysis blood loss was significantly associated with the open approach, higher ASA classification and malignancy as diagnosis. For LOS this was the open approach and a malignancy.

Conclusion

This international multicenter propensity score-matched study showed an advantage in favor of LRPS in selected patients as compared to ORPS in terms of operative time, blood loss and LOS without differences in major complications and R0 resection rate.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-08109-y) contains supplementary material, which is available to authorized users.

Laparoscopic versus open liver resections of posterolateral liver segments - a systematic review and meta-analysis

INTRODUCTION

Laparoscopic resection has become an accepted approach to liver tumour surgery. However, it is considered difficult, especially in unfavourably located lesions.

AIM

To compare the outcomes of laparoscopic (LLR) and open liver resection (OLR) of posterolateral segments.

MATERIAL AND METHODS

We searched the PubMed, EMBASE, and Scopus databases from inception to 30 September 2019. Full text articles and conference abstracts were included for further analysis. This review follows the PRISMA guidelines.

RESULTS

From 643 articles, 15 studies (N = 1196 patients) were included in the meta-analysis. All of them were non-randomised. Our findings showed that LLR had significantly lowered overall morbidity compared to OLR (MD = 0.66; 95% CI: 0.51-0.86; p = 0.002). Length of hospital stay (MD = 2.48; 95% CI: -3.87, -1.08; p < 0.001) was also shorter in the LLR group. Operative time (MD = 55.65; 95% CI: 24.14-87.16; p < 0.001) was significantly shorter in the OLR group. In terms of blood loss, major complications, R0 resection rates, and resection margin, there were no significant differences.

CONCLUSIONS

Our meta-analysis showed that the laparoscopic approach to resections of posterolateral liver segments is beneficial. However, the results are based on non-randomised trials, and further research is needed to fully establish their clinical application.

Short-term Outcomes of "Difficult" Laparoscopic Liver Resection at Specialized Centers: Report From INSTALL (International Survey on Technical Aspects of Laparoscopic Liver Resection)-2 on 4478 Patients

OBJECTIVE

To define the current status of "difficult" LLR, a global database was created and investigated.

BACKGROUND

In the Second International Consensus Conference in 2014, minor LLR was considered as a standard practice and major LLR remained an innovative procedure. Since then, no updates on worldwide trends have been available.

METHODS

A questionnaire on all consecutive patients who underwent difficult LLR (major hepatectomy, posterosuperior segmentectomy, sectionectomy, living donor hepatectomy, tumor size ≥10 cm, Child-Pugh grade ≥B, combined with biliary reconstruction, and Iwate criteria difficulty score ≥7) in 2014-2018 was distributed via email to 65 high-volume LLR centers worldwide. Individual data on patient and tumor demographics, surgical information, and short-term outcomes were obtained to create a large-scale international registry for analyses.

RESULTS

Overall, 58 centers in 19 countries performed 4478 difficult LLR (median, 58.5; range, 5-418) during the study period. Hepatocellular carcinoma accounted for ≥40% of all indications. Half of the patients underwent major hepatectomy, followed by sectionectomy, posterosuperior segmentectomy, and living donor hepatectomy. In the vast majority of procedures, Clavien-Dindo grade ≥IIIa complication rates of ≈10% and 90-day mortality rates of ≈1% were achieved. Left or right trisectionectomy had the worst Clavien-Dindo grade ≥IIIa complication rate of ≥10% and 90-day mortality rate of 5%-10%. No significant correlation was observed between center volume and short-term outcomes.

CONCLUSIONS

Total 4478 patients underwent difficult LLR worldwide in 2014-2018. Most procedures are safe and feasible when conducted in specialized centers.

Anatomic Laparoscopic Liver Resection in the Scenario of the Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis

Aim: To assess the impact of the laparoscopic anatomic resections (LARs) on hepatocellular carcinoma (HCC) patients, analyzing the pooled short- and long-term outcomes of this technique and comparing it with the standard open approach [open anatomic resections (OAR)]. Material and Methods: A systematic literature search was performed in PubMed, Embase, and Scopus for studies published between 2010 and 2020 concerning LAR for HCC. Results: After screening 311 articles, 10 studies with a total of 398 patients who underwent LAR for HCC were included. The pooled cohort included mostly male (76.6%), Child A (98.2%), with hepatitis B virus (HBV)-related disease (60.5%). The pooled conversion rate was 7.3%. The pooled overall complication rate was 10.2 with a mortality rate of 1.0%. In the pooled analyses of only comparative studies, LAR group included 378 versus 455 in OAR. Operative time was longer in the LAR group (329 minutes versus 248; P = .001). Blood loss (179 versus 331 mL; P = .018) was lower in the LAR group. The pooled mean length of hospital stay was 8.4 days in LARs and 11.3 in OARs (P = .002). The pooled rate of postoperative complications was higher in the OAR group (25.3 versus 13.8; P = .009), while mortality rates were similar. The LAR group had a pooled 3- and 5-year overall survival of 90.1 and 81.9 versus 83.5 and 80.7 of the OARs (P > .05), respectively. Conclusions: In conclusion, the LAR for HCC is safe and associated with decreased blood loss and length of hospital stay. Survival rates are comparable with those of the conventional open approach.

Feasibility of laparoscopic liver resection for liver cavernous hemangioma: A single-institutional comparative study

Backgrounds/Aims

While minimal invasive surgery has become popular, the feasibility of laparoscopy for liver cavernous hemangioma has not been shown.

Methods

Patients who underwent hepatectomy for liver cavernous hemangioma from January 2008 to February 2019 at the Samsung Medical Center were reviewed. Patients who underwent trisectionectomy were excluded. Background characteristics, along with operative and postoperative recovery, were compared between the laparoscopy and open surgery groups.

Results

Forty-three patients in the laparoscopy group and 33 patients in the open surgery group were compared. The differences in the background characteristics were presence of symptoms (14.6% in laparoscopy vs. 57.1% in open, p<0.001) and tumor location (right, left and both side p=0.017). The laparoscopy group had smaller blood loss (p=0.001), lesser blood transfusion requirements (p=0.035), lower level of post-operative total bilirubin, prothrombin time (INR) (p=0.001, 0.003 each), shorter hospital stay (p=0.001), earlier soft diet start (p<0.001), earlier drain removal (p<0.001) and shorter amount and duration of additional pain control (p=0.001, p=0.017 each). There was no significant difference in complication after surgery between two groups (p=0.721). All the patients showed pathologic report of benign hemangioma regardless of type of surgery (100%). Almost every patients reported no symptom or relief of symptom in both groups (97.7%, 93.9% each).

Conclusions

Laparoscopic liver resection for liver cavernous hemangioma can be safely performed with improved postoperative recovery. However, surgery for liver cavernous hemangioma should be conducted with informed consent of the patients.

Surgical and oncological outcomes after laparoscopic vs. open major hepatectomy for hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND

The short- and long-term prognoses are unclear following laparoscopic major hepatectomy (LMH) for hepatocellular carcinoma (HCC). We performed a meta-analysis to compare the surgical and oncological outcomes of LMH vs. open major hepatectomy (OMH) in patients with HCC.

METHODS

All studies comparing LMH with OMH for HCC published until April 2019 were identified independently by searching PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials. We analyzed data for surgical and oncological outcomes, namely, operative time, intraoperative blood loss, blood transfusion rate, postoperative morbidity, major complications, mortality, hospital stay, margin distance, negative margin rate, long-term overall survival, and corresponding disease-free survival (DFS).

RESULTS

We included 13 studies involving 1,225 patients with HCC (LMH: 534 patients; OMH: 691 patients) in the meta-analysis. Regarding short-term outcomes, the pooled data showed that LMH was associated with longer operative time [weighted mean difference (WMD): 72.14 min; 95% confidence interval (CI): 43.07-101.21; P<0.00001], less blood loss (WMD: -102.32 mL; 95% CI: -150.99 to -53.64; P<0.0001), shorter hospital stay (WMD: -3.77 d; 95% CI: -4.95 to -2.60; P<0.00001), lower morbidity [risk difference (RD): -0.01; 95% CI: -0.16 to -0.06; P<0.00001], and lower major complication rates (RD: -0.08; 95% CI: -0.11 to -0.05; P<0.00001). However, the need for blood transfusion (RD: -0.01; 95% CI: -0.06 to 0.05; P=0.78), mortality (RD: -0.01; 95% CI: -0.02 to 0.01; P=0.57), margin distance (WMD: 0.05 mm; 95% CI: -0.1 to 0.19; P=0.52), and negative margin rate (RD: 0.01; 95% CI: -0.03 to 0.05; P=0.65) were significantly comparable between the two groups. Regarding long-term outcomes, there was no difference in 3-year DFS [hazard ratio (HR): 0.99; 95% CI: 0.72-1.37; P=0.95], 3-year overall survival (HR: 1.25; 95% CI: 0.70-2.21; P=0.45), 5-year DFS (HR: 0.94; 95% CI: 0.64-1.38; P=0.76), and 5-year overall survival (HR: 0.94; 95% CI: 0.45-1.99; P=0.88).

CONCLUSIONS

LMH can be performed as safely as OMH in select patients and provides improved short-term surgical outcomes without affecting long-term survival. However, confirming our results requires more evidence from high-quality and prospective randomized controlled trials.

A novel exposure maneuver in laparoscopic right hepatectomy

BACKGROUND AND OBJECTIVES

Laparoscopic access to the posterosuperior and lateral parts of the right liver is difficult for blocked and deep surgical situations. We invented a novel water bag device (WBD) to improve the exposure of the right liver.

METHODS

Eighteen consecutive patients with lesions isolated to the posterosuperior or lateral right liver were included in our research. They underwent laparoscopic right hepatectomy with the help of the device and were compared with previous similar laparoscopic cases of our operating surgeon.

RESULTS

The device was successfully employed without related complications and provided enhanced and stable surgical exposure. All patients were operated on without the need for blood transfusions or laparotomy conversion. The median operation time and estimated blood loss were 227 minutes (range, 114-568) and 88 mL (range, 25-250), respectively. In all cases, tumor-free surgical margins were confirmed and no major complications were observed. The results were better than those in previous similar laparoscopic cases.

CONCLUSIONS

The WBD is safe and effective for laparoscopic exposure when lesions are located in the posterosuperior and lateral parts of the right liver. With the help of the device, laparoscopic right liver resection is easier to perform instead of undergoing open hepatectomy.

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.

Is the treatment outcome of hepatocellular carcinoma inferior in elderly patients?

In view of the increasing life expectancy in different parts of the world, a larger proportion of elderly patients with hepatocellular carcinoma (HCC) requiring oncological treatment is expected. The clinicopathological characteristics of HCC in elderly patients and in younger patients are different. Elderly patients, in general, also have more comorbidities. Evaluation of the efficacy of different HCC treatment options in elderly patients is necessary to optimize treatment outcomes for them. Treatment modalities for HCC include hepatectomy, liver transplantation, radiofrequency ablation, transarterial chemoembolization, and molecular-targeted therapy with sorafenib. In this review, current evidence on the risks and outcomes of the different HCC treatments for elderly patients are discussed. According to data in the literature, elderly patients and younger patients benefited similarly from HCC treatments. More clinical data are needed for the determination of selecting criteria on elderly HCC patients to maximize their chance of getting the most appropriate and effective treatments. As such, further studies evaluating the outcomes of different HCC treatment modalities in elderly patients are warranted.

Intraoperative Ultrasonography as a Guidance for Dividing Bile Duct During Laparoscopic Living Donor Hepatectomy

Background

The purpose of this study was to investigate the feasibility of using intraoperative ultrasonography as a guidance in dividing bile duct during laparoscopic donor hepatectomy.

Material/Methods

Cases of living liver donors who underwent laparoscopic living donor hepatectomy from May 2013 to December 2017 were reviewed. Operative and postoperative data were compared between donors with intraoperative ultrasonography and donors with intraoperative cholangiography. For analyzing whether bile duct division was performed successfully, anatomical type and number of bile duct openings were reviewed. When the number of bile ducts were achieved as expected, it was considered “successful”.

Results

Intraoperative cholangiography was used in 67 donors (62.6%) while intraoperative ultrasonography was used in 36 donors (33.6%). Mean operation time was 405.0±76.2 minutes versus 275.1±37.5 minutes, P<0.001, respectively, and was longer in donors who had a cholangiography. There was no difference in the success rate of bile duct division between donors who had a cholangiography (92.5%) and donors who had an ultrasonography (88.9%, P=0.716). The mean hospital stay after operation was longer in donors who had a cholangiography (11.6±4.3 days versus 9.0±2.7 days, P<0.001). There was no difference in biliary complication rate between donors who had a cholangiography (11.9%) and donors who had an ultrasonography (8.3%, P=0.743).

Conclusions

Intraoperative ultrasonography can be used safely in dividing bile duct during laparoscopic living donor hepatectomy with similar outcomes to intraoperative cholangiography.

Laparoscopic Donor Hepatectomy for Adult Living Donor Liver Transplantation Recipients

Even after 2 decades of experience in laparoscopic hepatectomy, data on purely laparoscopic approach for donor hepatectomy in adult living donor liver transplantation (LDLT) are limited. We report our initial experience of a purely laparoscopic approach for donor hepatectomy for adult recipients to explore its potential application in the management of donors. We did a retrospective data analysis of 54 consecutive patients operated on between May 2013 and February 2015. There were 41 right, 10 extended right, and 3 left hepatectomies. The median operative time was 436 minutes (range 294-684 minutes), and warm ischemia time was 6 minutes (2-12 minutes). Estimated blood loss was 300 mL (10-850 mL), and none of the patients required intraoperative transfusion. Four cases were converted to open laparotomy. The major complication rate was 16.7%, and biliary complication was the most frequent cause. Patients with normal anatomy had a major complication rate of 9.3% as compared with 45.5% in patients with anatomic variations. All patients recovered, and there was no mortality. In conclusion, a purely laparoscopic donor hepatectomy for adult LDLT recipients seems to be a feasible option; with careful patient selection and when performed by experienced surgeons, it may afford results comparable to the open method.

Laparoscopy of hepatocellular carcinoma is helpful in minimizing intra-abdominal adhesion during salvage transplantation

Purpose

This study analyzes the impact of laparoscopic liver resection on intra-abdominal adhesion.

Methods

Patients who underwent salvage liver transplantation after liver resection for hepatocellular carcinoma from January 2012 to October 2017 at our institution were included. Information about the severity of intra-abdominal adhesions was collected from a prospectively maintained database. Intra-abdominal adhesions were graded after the agreement of 2 surgeons who participated in the salvage liver transplantation based on predetermined criteria. Adhesion severity and demographic, operative, and postoperative data were compared between the laparoscopic group and the open group. Multivariate logistic regression was performed to consider potential factors related to severe adhesion during salvage transplantation.

Results

Sixty-two patients who underwent salvage liver transplantation after liver resection were included in this study. Among them, 52 patients underwent open surgery, and 10 patients underwent laparoscopy. Adhesion was significantly more severe in the open group than in the laparoscopy group (P = 0.029). A multivariate logistic regression model including potential factors related to severe adhesion showed that laparoscopy (odds ratio, 0.168; 95% confidence interval, 0.029–0.970; P = 0.048) was the only significant factor.

Conclusion

Laparoscopic liver resection for hepatocellular carcinoma can minimize intra-abdominal adhesion during salvage liver transplantation.

Laparoscopic hepatectomy for elderly patients: Major findings based on a systematic review and meta-analysis

BACKGROUND

As the general population continues to age, there is an increase need for surgical management of elderly patients. Compared to open hepatectomy (OH), laparoscopic hepatectomy (LH) offers earlier mobilization, less blood loss, and shorter postoperative hospital stay. However, whether these advantages of LH over OH are retained in elderly patients remains to be clarified. Therefore, in this study, we sought to evaluate the feasibility, safety, and potential benefits of LH for elderly patients.

METHODS

A systematic search of PubMed, Embase, Cochrane Library, and Web of Science was performed to identify studies that compared LH and OH. Studies comparing LH in elderly and LH in nonelderly patients were also identified. Outcomes of interest included conversion rate, operative time, intraoperative estimated blood loss, length of hospital stay, rate and type of morbidity, mortality rate, margin status (R0), and long-term oncologic outcomes.

RESULTS

Nine studies met our inclusion criteria for this analysis. Of these, 5 compared LH and OH in elderly patients, 3 compared LH in elderly and nonelderly patients, and 1 included both outcomes. Compared to those with OH, elderly patients who underwent LH had similar operative times [weighted mean difference (WMD) = 1.15 minutes; 95% confidence interval (CI): -28.28-30.59, P = .94], less intraoperative blood loss (WMD = -0.71 mL; 95% CI: -1.29 to -0.16, P = .01), a lower rate of transfusion [risk ratio (RR) = 0.61, 95% CI: 0.40-0.94, P = .02], comparable R0 rates (RR = 1.01; 95% CI: 0.96-1.07, P = .70), less postoperative complications (RR = 0.61, 95% CI: 0.48-0.76, P < .01), and shorter hospital stay (WMD = -3.22 days; 95% CI: -4.21 to -2.23, P < .01). The limited long-term outcomes indicated that survival status was comparable between LH and OH for elderly patients. The pooled outcomes for elderly versus nonelderly patients indicated that the safety and effectiveness of LH over OH in elderly patients was not inferior to those in nonelderly patients.

CONCLUSION

Our results indicate that LH is a feasible and safe alternative to OH in elderly patients, providing a lower rate of morbidity and favorable postoperative recovery and outcomes.