Laparoscopic liver resection in cirrhotic patients with specific reference to a difficulty scoring system

Perioperative impact of liver cirrhosis on robotic liver resection for hepatocellular carcinoma: a retrospective cohort study

BACKGROUND

The safety and efficacy of robotic liver resection (RLR) for patients with hepatocellular carcinoma (HCC) have been reported worldwide. However, the exact role of RLR in HCC patients with liver cirrhosis is not sufficiently determined.

METHODS

We conducted a retrospective study on consecutive patients with cirrhosis or non-cirrhosis who received RLR for HCC from 2018 to 2023. Data on patients' demographics and perioperative outcomes were collected and analyzed. Propensity score matching (PSM) analysis was performed. Multivariate logistic regression analysis was performed to determine the risk factors of prolonged postoperative length of stay (LOS) and morbidity.

RESULTS

Of the 571 patients included, 364 (64%) had cirrhosis. Among the cirrhotic patients, 48 (13%) were classified as Child-Pugh B. After PSM, the cirrhosis and non-cirrhosis group (n = 183) had similar operative time, estimated blood loss, postoperative blood transfusion, LOS, overall morbidity (p > 0.05). In addition, the intraoperative and postoperative outcomes were similar between the two groups in the subgroup analyses of patients with tumor size ≥ 5 cm, major hepatectomy, and high/expert IWATE difficulty grade. However, patients with Child-Pugh B cirrhosis had longer LOS and more overall morbidity than that of Child-Pugh A. Child-Pugh B cirrhosis, ASA score > 2, longer operative time, and multiple tumors were risk factors of prolonged LOS or morbidity in patients with cirrhosis.

CONCLUSION

The presence of Child-Pugh A cirrhosis didn't significantly influence the difficulty and perioperative outcomes of RLR for selected patients with HCC. However, even in high-volume center, Child-Pugh B cirrhosis was a risk factor for poor postoperative outcomes.

Impact of Liver Cirrhosis, Severity of Cirrhosis, and Portal Hypertension on the Difficulty and Outcomes of Laparoscopic and Robotic Major Liver Resections for Primary Liver Malignancies

BACKGROUND

Minimally invasive liver resections (MILR) offer potential benefits such as reduced blood loss and morbidity compared with open liver resections. Several studies have suggested that the impact of cirrhosis differs according to the extent and complexity of resection. Our aim was to investigate the impact of cirrhosis on the difficulty and outcomes of MILR, focusing on major hepatectomies.

METHODS

A total of 2534 patients undergoing minimally invasive major hepatectomies (MIMH) for primary malignancies across 58 centers worldwide were retrospectively reviewed. Propensity score (PSM) and coarsened exact matching (CEM) were used to compare patients with and without cirrhosis.

RESULTS

A total of 1353 patients (53%) had no cirrhosis, 1065 (42%) had Child-Pugh A and 116 (4%) had Child-Pugh B cirrhosis. Matched comparison between non-cirrhotics vs Child-Pugh A cirrhosis demonstrated comparable blood loss. However, after PSM, postoperative morbidity and length of hospitalization was significantly greater in Child-Pugh A cirrhosis, but these were not statistically significant with CEM. Comparison between Child-Pugh A and Child-Pugh B cirrhosis demonstrated the latter had significantly higher transfusion rates and longer hospitalization after PSM, but not after CEM. Comparison of patients with cirrhosis of all grades with and without portal hypertension demonstrated no significant difference in all major perioperative outcomes after PSM and CEM.

CONCLUSIONS

The presence and severity of cirrhosis affected the difficulty and impacted the outcomes of MIMH, resulting in higher blood transfusion rates, increased postoperative morbidity, and longer hospitalization in patients with more advanced cirrhosis. As such, future difficulty scoring systems for MIMH should incorporate liver cirrhosis and its severity as variables.

The preoperative M2BPGi score predicts operative difficulty and the incidence of postoperative complications in laparoscopic liver resection

BACKGROUND

Liver fibrosis or cirrhosis frequently makes parenchymal transection more difficult, but the difficulty score of laparoscopic liver resection (LLR), including the IWATE criteria, does not include a factor related to liver fibrosis. Therefore, this study aimed to evaluate M2BPGi as a predictor of the difficulty of parenchymal transection and the incidence of postoperative complications in LLR.

METHODS

Data from 54 patients who underwent laparoscopic partial liver resection (LLR-P) and 24 patients who underwent laparoscopic anatomical liver resection between 2017 and 2019 in our institution were retrospectively analyzed. All cases were classified according to M2BPGi scores, and reserve liver function, intraoperative blood loss, and postoperative complications were compared among these groups.

RESULTS

Sixteen cases (29.6%) were M2BPGi negative (cut-off index < 1.0), 25 cases (46.3%) were 1+ (1.0 ≤ cut-off index < 3.0), and 13 cases (24.1%) were 2+ (cut-off index ≥ 3.0). M2BPGi-positive cases had significantly worse hepatic reserve function (K-ICG: 0.16 vs 0.14 vs 0.08, p < 0.0001). Intraoperative bleeding was significantly greater in M2BPGi-positive cases [50 ml vs 150 ml vs 200 ml, M2BPGi (-) or (1+) vs M2BPGi (2+), p = 0.045]. Postoperative complications (Clavien-Dindo ≥ II) were significantly more frequent in M2BPGi-positive cases [0% vs 4% vs 33%, M2BPGi (-) or (1+) vs M2BPGi (2+), p = 0.001].

CONCLUSION

M2BPGi could predict surgical difficulty and complications in LLR-P. In particular, it might be better not to select M2BPGi (2+) cases as teaching cases because of the massive bleeding during parenchymal transection.

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.

A novel difficulty scoring system of laparoscopic liver resection for liver tumor

Objectives

To develop a novel difficulty scoring system (NDSS) to predict the surgical difficulty of laparoscopic hepatectomy.

Patients and methods

A total of 138 patients with liver tumors performed liver resection (LLR) between March 2017 to June 2022 were selected from Affiliated Hospital of Jiangnan University and Wujin Hospital Affiliated with Jiangsu University.

Patient demographics, laboratory tests, intraoperative variables, pathological characteristics were assessed. We also assessed the Child Pugh score and the DSS-B score.

Results

Patients were divided into training and testing cohort according to their hospital. Patients in training cohort were divided into high and low difficult groups based on operation time, blood loss and conversion. Higher percentage of patients with malignant liver tumor (87.0% vs. 58.1%; P = 0.003) or history of hepatobiliary surgery (24.1% vs. 7.0%; P = 0.043) in high difficult group than in low difficult group. To improve the difficulty scoring system, we incorporated the history of hepatobiliary surgery and nature of the tumor. A novel difficulty scoring system was established. The results showed that the operation time (P < 0.001), blood loss (P < 0.001), ALT (P < 0.001) and AST (P = 0.001) were associated with the novel difficulty score significantly. Compared with DSS-B, the NDSS has a higher area under the receiver operating characteristic (AUROC) (0.838 vs. 0.814). The nomogram was established according to the NDSS. The AUROCs of the nomogram in training and testing cohort were 0.833 and 0.767. The calibration curves for the probability of adverse event showed optimal agreement between the probability as predicted by the nomogram and the actual probability.

Conclusions

We developed a nomogram with the NDSS that can predict the difficulty of LLR. This system could more accurately reflect the difficulty of surgery and help liver surgeons to make the surgical plan and ensure the safety of the operation.

Minimally Invasive Liver Surgery: A Snapshot from a Major Dutch HPB and Transplant Center

BACKGROUND

Minimally invasive liver surgery (MILS) has been progressively adopted on a nationwide scale. The aim of this study is to investigate MILS implementation in a high-volume Dutch hepato-pancreato-biliary and transplant center, which is considered a moderate to low-volume center from a European standpoint.

METHODS

All patients who underwent MILS at Erasmus Medical Center between April 2010 and December 2021 were retrospectively reviewed. Patients' surgical outcomes were compared after stratification according to resections' difficulty and liver cirrhosis.

RESULTS

A total of 212 cases were included. Major liver resections were performed in 24 patients (11%), while minor resections were performed in 188 patients (89%). Among those, 177 (94%) resections were classified as technically minor and 11 (6%) as technically major. Major morbidity was reported in 14/177 patients (8%) after technically minor resections and in 3/24 patients (13%) after major resections. Anatomically and technically major resections had higher intraoperative blood losses (425 (0-2100) vs. 240 (50-110) vs. 100 (0-2400) mL; p-value < 0.001) and longer hospital stay (6 (3-25) vs. 5 (2-9) vs. 3 (1-44); p-value < 0.001) when compared with the technically minor counterpart. Perioperative outcomes were similar when comparing cirrhotic MILS with the non-cirrhotic cohort.

CONCLUSION

MILS program implementation can lead to encouraging surgical outcomes even in low- to moderate-volume centers. Although low procedural volume might be predictive of impaired outcomes, long-standing experience in the HPB and liver transplant field could mitigate low-case volume effects on surgical outcomes.

Evaluation of the Iwate Model for Predicting the Difficulty of Laparoscopic Liver Resection: Does Tumor Size Matter?

BACKGROUND

This study aimed to externally validate the Iwate scoring model and its prognostic value for predicting the risks of intra- and postoperative complications of laparoscopic liver resection.

METHODS

Consecutive patients who underwent pure laparoscopic liver resection between 2008 and 2019 at a single tertiary center were included. The Iwate scores were calculated according to the original proposition (four difficulty levels based on six indices). Intra- and postoperative complications were compared across difficulty levels. Fitting the obtained data to the cumulative density function of the Weibull distribution and a linear function provided the mean risk curves for intra- and postoperative complications, respectively.

RESULTS

The difficulty levels of 142 laparoscopic liver resections were scored as low, intermediate, advanced, and expert level in 41 (28.9%), 53 (37.3%), 32 (22.5%), and 16 (11.3%) patients, respectively. Intraoperative complications were detected in 26 (18.3%) patients and its rates (2.4%, 7.5%, 34.3%, and 62.5%) increased gradually with statistically significant values among difficulty levels (P ˂ 0.001). Major postoperative complications occurred in 21 (14.8%) patients and its rates (4.8%, 5.6%, 28.1%, 43.7%; P ˂ 0.001) showed the same trend as for intraoperative complications. Then, the mean risk curves of both complications were obtained. Due to outliers, a new threshold for a tumor size index was proposed at 38 mm. The repeated analysis showed improved results.

CONCLUSIONS

The Iwate scoring model predicts the probability of complications across difficulty levels. Our proposed tumor size threshold (38 mm) improves the quality of the prediction. The model is upgraded by a probability of complications for every difficulty score.

Unravelling the Complexity Myth for Minimally Invasive Right Hepatectomy: Liver Parenchymal Features and their Correlation to Objective Outcomes in Major Anatomical Resections

BACKGROUND

Minimally invasive approaches to major liver resection have been limited by presumed difficulty of the operation. While some concerns arise from mastering the techniques, factors such as tumor size and liver parenchymal features have anecdotally been described as surrogates for operative difficulty. These factors have not been systematically studied for minimally invasive right hepatectomy (MIRH).

METHODS

Seventy-five patients who underwent MIRH during 2007-2016 by the senior author were evaluated; these were compared to control group of open right hepatectomy. Demographics, operative, and post-operative variables were collected. Operative times and estimated blood loss, two objective parameters of operative difficulty were correlated to volume of hepatic resection, parenchymal transection diameter and liver parenchymal features using regression analysis.

RESULTS

Thirty-eight (50.6%) resections were performed for malignant indications. Average tumor size was 5.7 cm (±3.6), mean operative time was 196 min (±74), and mean EBL was 220 mL (±170). Average transection diameter was 10.1 cm (±1.7). There was no correlation between operative difficulty with parenchymal transection diameter or presence of steatosis. Blood loss was higher with increased right hepatic lobe volume and body mass index.

CONCLUSIONS

This analysis of a very defined anatomical resection suggests that the often quoted radiographic and pathologic features indicative of a challenging procedure were not significant in determining operative difficulty.

Safety assessment of laparoscopic liver resection: A project study of the Endoscopic Liver Surgery Study Group of Japan

BACKGROUND/PURPOSE

Laparoscopic liver resection (LLR) has been expanded rapidly and has been accepted worldwide; however, the safety assessment of LLR has not been fully conducted with a large-scale cohort. The aim of this study was to assess safety and identify clinical factors associated with postoperative major complications in LLR.

METHODS

This project study retrospectively collected the data of LLRs performed before October 2015 in Japan. Patient characteristics, details of LLRs, and surgical outcomes were analyzed.

RESULTS

A total of 4122 patients from 66 institutions were enrolled. The main indications were hepatocellular carcinoma (HCC) and colorectal liver metastases. The majority of the procedures were performed for solitary tumor-located liver segment 2, 3, 5, and 6 and the partial resection and left-lateral sectionectomy occupied 77.3%. The rate of conversion, accidental events were 7.1% and 2.1%, respectively. Postoperative major complication occurred in 205 cases (5.0%), and 14 in-hospital deaths were found among HCC patients with chronically diseased liver. Occurrence of postoperative major complication was associated with operation time (≥360 minutes), intraoperative blood loss (≥250 mL), red blood cell transfusion (yes), and the difficulty score (≥6). The 30- and 90-day mortality was 0.14% and 0.41%, respectively.

CONCLUSIONS

Laparoscopic liver resection was performed with an acceptable rate of conversion, accidental events, morbidity, and mortality. The indications for LLR should be cautiously judged considering tumor location, planned operative procedure, and liver function.

Safety and feasibility for laparoscopic versus open caudate lobe resection: a meta-analysis

BACKGROUND

Laparoscopic hepatectomy has been used widely due to its advantages as a minimally invasive surgery. However, multicenter, large-scale, population-based laparoscopic caudate lobe resection (LCLR) versus open caudate lobe resection (OCLR) has rarely been reported. We assessed the feasibility and safety of LCLR compared with OCLR using meta-analysis.

METHODS

Relevant literature was retrieved using PubMed, Embase, Cochrane, Ovid Medline, Web of Science, CNKI, and WanFang Med databases up to July 30th, 2020. Multiple parameters of feasibility and safety were compared between the treatment groups. Quality of studies was assessed with the Newcastle-Ottawa Scale (NOS). The data were analyzed by Review Manager 5.3. Results are expressed as odds ratio (OD) or mean difference (MD) with 95% confidence interval (95% CI) for fixed- and random-effects models.

RESULTS

Seven studies with 237 patients were included in this meta-analysis. Compared with OCLR, the LCLR group had a lower intraoperative blood loss (MD - 180.84; 95% CI - 225.61 to - 136.07; P < 0.0001), shorter postoperative hospital stays (MD - 4.38; 95% CI - 7.07 to - 1.7; P = 0.001), shorter operative time (MD - 50.24; 95% CI - 78.57 to - 21.92; P = 0.0005), and lower rates in intraoperative blood transfusion (OR 0.12; P = 0.01). However, there were no statistically significant differences between LCLR and OCLR regarding hospital expenses (MD 0.92; P = 0.12), pedicle clamping (OR 1.57; P = 0.32), postoperative complications (OR 0.58; P = 0.15), bile leak (P = 0.88), ascites (P = 0.34), and incisional infection (P = 0.36).

CONCLUSIONS

LCLR has multiple advantages over OCLR, especially intraoperative blood loss and hospital stays. LCLR is a very useful technology and feasible choice in patients with caudate lobe lesions.

Comparative analysis of the safety and feasibility of laparoscopic versus open caudate lobe resection

PURPOSE

Laparoscopic hepatectomy has been used widely in liver disease due to its advantages as a minimally invasive surgery. However, laparoscopic caudate lobe resection (LCLR) has been reported rarely. We aimed to investigate the safety and feasibility of LCLR by comparing it with open liver surgery.

METHODS

A retrospective study was performed including all patients who underwent LCLR and open caudate lobe resection (OCLR) between January 2015 and August 2019. Twenty-two patients were involved in this study and divided into LCLR (n = 10) and OCLR (n = 12) groups based on preoperative imaging, tumor characteristics, and blood and liver function test. Patient demographic data and intraoperative and postoperative outcomes were compared between the two groups.

RESULTS

There were no significant inter-group differences between gender, age, preoperative liver function, American Society of Anesthesiologists (ASA) grade, and comorbidities (P > 0.05). The LCLR showed significantly less blood loss (50 vs. 300 ml, respectively; P = 0.004), shorter length of hospital stay (15 vs. 16 days, respectively; P = 0.034), and shorter operative time (216.50 vs. 372.78 min, respectively; P = 0.012) than OCLR, but hospital expenses (5.02 vs. 6.50 WanRMB, respectively; P = 0.208) showed no statistical difference between groups. There was no statistical difference in postoperative bile leakage (P = 0.54) and wound infection (P = 0.54) between LCLR and OCLR. Neither LCLR nor OCLR resulted in bleeding or liver failure after operation. There were no deaths.

CONCLUSION

LCLR is a very useful technology, and it is a feasible choice in selected patients with benign and malignant tumors in the caudate lobe.

A multicenter cohort analysis of laparoscopic hepatic caudate lobe resection

INTRODUCTION

Laparoscopic resection of the hepatic caudate lobe (LRCL) requires a high level of expertise due to its challenging anatomical area. Only case reports, case series, and single-center cohort studies have been published. The aim of this study was to assess the safety and feasibility of this laparoscopic procedure.

METHODS

A multicenter retrospective cohort study including all patients who underwent LRCL in 4 high-volume hepatobiliary units between January 2000 and May 2018 was performed. Perioperative, postoperative, and survival outcomes were assessed. Postoperative morbidity was stratified according to the Clavien-Dindo classification with severe complications defined by grade III or more. The Kaplan-Meier method was used for survival analysis.

RESULTS

A total of 32 patients were included, including 22 (68.8%) with colorectal liver metastasis (CRLM), one (3.1%) with cholangiocarcinoma, four (12.5%) with other malignancies, and five (15.6%) with symptomatic benign lesions. Simultaneous colorectal and/or additional liver resection was performed in 20 (62.5%) patients. The median (IQR) operative time was 155 (121-280) minutes, blood loss was 100 (50-275) ml, conversion rate was 9.4% (n = 3), severe complications were observed in 2 patients (6.3%), and median (range) length of hospital stay was 3 [1-39] days. No 90-day postoperative mortality was noticed. The median (IQR) follow-up for the CRLM group was 14 [10-23] months. Five-year overall survival rate was 82% in this subgroup. Small interinstitutional differences were observed without major impact on surgical outcomes.

CONCLUSION

LRCL is safe and feasible when performed in high-volume centers. Profound anatomical knowledge, advanced laparoscopic skills, and mastering intraoperative ultrasound are essential. No major interinstitutional differences were ascertained.

The external validation of a difficulty scoring system for predicting the risk of intraoperative complications during laparoscopic liver resection

BACKGROUND

This study aimed to externally validate and upgrade the recent difficulty scoring system (DSS) proposed by Halls et al. to predict intraoperative complications (IOC) during laparoscopic liver resection (LLR).

METHODS

The DSS was validated in a cohort of 128 consecutive patients undergoing pure LLRs between 2008 and 2019 at a single tertiary referral center. The validated DSS includes four difficulty levels based on five risk factors (neoadjuvant chemotherapy, previous open liver resection, lesion type, lesion size and classification of resection). As established by the validated DSS, IOC was defined as excessive blood loss (> 775 mL), conversion to an open approach and unintentional damage to surrounding structures. Additionally, intra- and postoperative outcomes were compared according to the difficulty levels with usual statistic methods. The same five risk factors were used for validation done by linear and advanced nonlinear (artificial neural network) models. The study was supported by mathematical computations to obtain a mean risk curve predicting the probability of IOC for every difficulty score.

RESULTS

The difficulty level of LLR was rated as low, moderate, high and extremely high in 36 (28.1%), 63 (49.2%), 27 (21.1%) and 2 (1.6%) patients, respectively. IOC was present in 23 (17.9%) patients. Blood loss of >775 mL occurred in 8 (6.2%) patients. Conversion to open approach was required in 18 (14.0%) patients. No patients suffered from unintentional damage to surrounding structures. Rates of IOC (0, 9.5, 55.5 and 100%) increased gradually with statistically significant value among difficulty levels (P < 0.001). The relations between the difficulty level, need for transfusion, operative time, hepatic pedicle clamping, and major postoperative morbidity were statistically significant (P < 0.05). Linear and nonlinear validation models showed a strong correlation (correlation coefficients 0.914 and 0.948, respectively) with the validated DSS. The Weibull cumulative distribution function was used for predicting the mean risk probability curve of IOC.

CONCLUSION

This external validation proved this DSS based on patient's, tumor and surgical factors enables us to estimate the risk of intra- and postoperative complications. A surgeon should be aware of an increased risk of complications before starting with more complex procedures.

Novel patient risk factors and validation of a difficulty scoring system in laparoscopic repeat hepatectomy

The indications for laparoscopic liver resection have expanded; however, the safety and benefits of laparoscopic repeat hepatectomy (LRH) remain unclear. We retrospectively reviewed data from 137 patients who underwent partial hepatectomy or left lateral sectionectomy without thoracotomy. We compared patients’ clinical factors using a difficulty scoring system for LRH. We defined factors associated with blood loss volumes in the 75th percentile or above as risk factors for bleeding in open repeat hepatectomy, and determined whether these factors were useful for LRH risk assessment. Open repeat hepatectomy and LRH was performed in 96 and 41 patients, respectively. Four of 41 (9.8%) patients undergoing LRH were converted to laparotomy. Blood loss volume was significantly greater in the intermediate-risk group than in the low-risk group (P = 0.046). Multivariate analysis revealed that the presence of tumours located adjacent and caudal or dorsal to the primary tumour site was an independent risk factor for bleeding in LRH (odds ratio 3.21, 95% confidence interval 1.16–8.88, P = 0.024). Our study validated the usefulness of a difficulty scoring system, identified patient factors that predicted the difficulty of LRH, and presented a novel difficulty scoring system for LRH based on an existing difficulty scoring system.