LigaSure versus CUSA for parenchymal transection during laparoscopic hepatectomy in hepatocellular carcinoma patients with cirrhosis: a propensity score-matched analysis

Liver Resection for Hepatocellular Carcinoma: Recent Advances

Hepatocellular carcinoma (HCC) represents a significant global health burden. Surgery remains a cornerstone in the curative treatment of HCC, and recent years have witnessed notable advancements aimed at refining surgical techniques and improving patient outcomes. This review presents a detailed examination of the recent innovations in HCC surgery, highlighting key developments in both surgical approaches and adjunctive therapies. Advanced imaging technologies have revolutionized preoperative assessment, enabling precise tumour localization and delineation of vascular anatomy. The use of three-dimensional rendering has significantly augmented surgical planning, facilitating more accurate and margin-free resections. The advent of laparoscopic and robotic-assisted surgical techniques has ushered in an era of minimal access surgery, offering patients the benefits of shorter hospital stays and faster recovery times, while enabling equivalent oncological outcomes. Intraoperative innovations such as intraoperative ultrasound (IOUS) and fluorescence-guided surgery have emerged as valuable adjuncts, allowing real-time assessment of tumour extent and aiding in parenchyma preservation. The integration of multimodal therapies, including neoadjuvant and adjuvant strategies, has allowed for 'bio-selection' and shown the potential to optimize patient outcomes. With the advent of augmented reality and artificial intelligence (AI), the future holds immense potential and may represent significant strides towards optimizing patient outcomes and refining the standard of care.

Autologous blood transfusion reduces the requirement for perioperative allogenic blood transfusion in patients undergoing major hepatopancreatobiliary surgery: a retrospective cohort study

INTRODUCTION

Major hepatopancreatobiliary surgery is associated with a risk of major blood loss. The authors aimed to assess whether autologous transfusion of blood salvaged intraoperatively reduces the requirement for postoperative allogenic transfusion in this patient cohort.

MATERIALS AND METHODS

In this single centre study, information from a prospective database of 501 patients undergoing major hepatopancreatobiliary resection (2015-2022) was analysed. Patients who received cell salvage ( n =264) were compared with those who did not ( n =237). Nonautologous (allogenic) transfusion was assessed from the time of surgery to 5 days postsurgery, and blood loss tolerance was calculated using the Lemmens-Bernstein-Brodosky formula. Multivariate analysis was used to identify factors associated with allogenic blood transfusion avoidance.

RESULTS

32% of the lost blood volume was replaced through autologous transfusion in patients receiving cell salvage. Although the cell salvage group experienced significantly higher intraoperative blood loss compared with the noncell salvage group (1360 ml vs. 971 ml, P =0.0005), they received significantly less allogenic red blood cell units (1.5 vs. 0.92 units/patient, P =0.03). Correction of blood loss tolerance in patients who underwent cell salvage was independently associated with avoidance of allogenic transfusion (Odds ratio 0.05 (0.006-0.38) P =0.005). In a subgroup analysis, cell salvage use was associated with a significant reduction in 30-day mortality in patients undergoing major hepatectomy (6 vs. 1%, P =0.04).

CONCLUSION

Cell salvage use was associated with a reduction in allogenic blood transfusion and a reduction in 30-day mortality in patients undergoing major hepatectomy. Prospective trials are warranted to understand whether the use of cell salvage should be routinely utilised for major hepatectomy.

Laparoscopic Liver Resection Utilizing a Water Jet Scalpel for Patients With Liver Fibrosis

Introduction A variety of devices are utilized in order to resect liver parenchyma in laparoscopic liver resection. However, liver fibrosis makes hepatectomy problematic because the liver is rigid and prone to bleeding. The water jet scalpel, which dissociates the liver parenchyma with a jet stream has no thermal damage and is clinically utilized in liver resection, but its safety and efficacy during laparoscopic liver resection for patients with liver fibrosis remain unknown. Methods We analyzed patients who underwent laparoscopic liver resection utilizing the water jet scalpel with liver fibrosis at our hospital. A water jet scalpel was used for liver parenchymal transection, and a saline-linked ball-tipped electrocautery was simultaneously used for hemostasis. Results Subsectionectomy was one case, left lateral sectionectomy was two cases, and non-anatomical liver resection was three cases. The median blood loss was 70 mL (24-104 mL). There was no need for the intraoperative Pringle's maneuver. No perioperative blood transfusion was performed, and there were no postoperative complications, including posthepatectomy liver failure. Conclusion It was suggested that laparoscopic liver resection in patients with liver fibrosis can be safely performed with the water jet scalpel.

Comparison of efficacy and safety of robotic surgery and laparoscopic surgery for choledochal cyst in children: a systematic review and proportional meta-analysis

BACKGROUND

Most commonly, cyst excision and Roux-en-Y hepaticojejunostomy reconstruction are the optimal treatment for choledochal cysts (CC). Robotic surgery (RS) is being conducted with increasing frequency to treat CC. It is unclear whether RS can overcome the limitations of laparoscopic surgery (LS) and improve the prognosis of patients. In terms of efficacy, evidence concerning which minimally invasive surgery is preferred is, however, sparse. Our objective is to further compare the efficacy of RS and LS in children with CC and draw a useful clinical conclusion.

METHODS

Studies meeting inclusion criteria were identified from a series of databases, consisting of PubMed, Embase, Scopus, Web of Science, the Cochrane Library and their reference list of articles up to May 2022. Eligible articles comprised at least five objects that were younger than 18 years of age and the language was limited to English. Two authors independently evaluated selected studies and extracted data for analysis.

RESULTS

Forty studies were selected for analysis, with thirty-six reporting data on LS and eight containing data on RS. The pooled conversion rate and pooled postoperative complication rate of RS were lower than those of LS, but none of them was statistically significant. Moreover, comparisons of the following detailed postoperative complication rates were not statistically significant, such as intestinal obstruction or ileus, anastomotic bleeding, anastomotic or bile leakage, and anastomotic stenosis. However, the intraoperative blood loss and the postoperative hospital stay in RS group were significantly lower than those in LS group.

CONCLUSIONS

RS is a safe and feasible option for children with CC. Further studies with more cases, long-term efficacy and health economics analysis are needed to confirm whether RS is more advantageous.

Laparoscopic liver resection with "ultrasonic scalpel mimic CUSA" technique

BACKGROUND

Liver parenchymal transection is the most critical step for laparoscopic liver resection (LLR). Ultrasonic scalpel (Harmonic) is a common used energy instrument in LLR; however, it is only recommended for superficial layer transection and the Cavitron Ultrasonic Surgical Aspirator (CUSA) is recommended for deep layer dissection. We herein introduce the "Harmonic mimic CUSA" technique for LLR.

METHODS

We retrospectively reviewed the medical records of the patients who underwent LLR using CUSA or the "Harmonic mimic CUSA" for parenchymal transection between July 2018 and October 2020 at West China Hospital of Sichuan University. Observation indicators included general demographic information, operative time, intraoperative blood loss, blood transfusion volume, complication rate, hospital stay, and the costs. Perioperative data was compared between the two groups by propensity score matching analysis (PSM).

RESULTS

A total of 298 patients, including 192 in Harmonic group and 106 in CUSA group, were enrolled in this study. After a 1:1 PSM, 99 patients using "Harmonic mimic CUSA" were matched with 99 patients via CUSA for parenchymal transection in LLRs. The Harmonic group had significantly less intraoperative blood loss (mean, 150 ml vs. 250 ml, P < 0.001), shorter operative time (mean 170 min vs. 250 min, P < 0.001) and less costs (mean 6723$ vs. 8307$, P < 0.001). The conversion to laparotomy, length of postoperative hospital stay, complications were comparable between the two groups. There perioperative mortality was nil.

CONCLUSION

The "Harmonic mimic CUSA" technique is safe, simple and feasible for LLR, which may be an alternative to CUSA for LLR.

Influence of the water jet system vs cavitron ultrasonic surgical aspirator for liver resection on the remnant liver

BACKGROUND

Several methods, such as finger fracture, Pean crush, cavitron ultrasonic surgical aspirator (CUSA), and water jet (WJ), are used for hepatic parenchymal dissection in liver surgery. CUSA is the conventional method in Japan. WJ is a relatively novel method for parenchymal dissection. Although it has several advantages, such as lower volume of blood loss and shorter operative time, the effect of the WJ system for hepatic dissection on the remnant liver has not yet been investigated.

AIM

To investigate and compare the effect of the WJ method vs CUSA on the remnant liver cut surface.

METHODS

This observational study compared the two types of parenchymal transection methods (WJ vs CUSA) in liver surgery. In total, 24 and 40 patients who underwent hepatectomy using the WJ method and CUSA, respectively, were included in the analysis. Accordingly, the clinicopathological characteristics and clinical outcomes of 24 and 40 patients were compared. Furthermore, postoperative contrast-enhanced computed tomography (CT) scan was performed to assess the cut surface length of the remnant liver and the degenerative thickness of the areas with a reduced contrast effect in the dissected plane. Then, the two groups were compared.

RESULTS

On CT scan, the median areas of denaturation in the liver dissection planes were 522 (range: 109.5-1242) mm² in the CUSA group and 324 (range: 93.6-1529) mm² in the WJ group. The area did not significantly differ between the two groups; however, the denaturation thickness of the WJ group was significantly lower than that of the CUSA group [5.8 (range: 0.7-11.1) mm vs 3.3 (range: 1.7-10.4) mm, P < 0.001].

CONCLUSION

The WJ group had significantly thinner contrast-enhanced areas in the post hepatectomy detached section than the CUSA group.

Laparoscopic versus open liver resection for resectable HCC with BCLC stage B: a propensity score-matched analysis

To date, there is little knowledge about the value of laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) patients with Barcelona Clinic Liver Cancer (BCLC) stage B. Thus, this study was performed to assess the perioperative and oncological outcomes of LLR for these patients by comparison with open liver resection (OLR). Between April 2015 and October 2018, a total of 217 resectable HCC patients with BCLC stage B were eligible for this study. Patients were divided into the LLR group and the OLR group according to different procedures. Propensity score matching (PSM) was conducted to adjust for known confounders. Short- and long-term outcomes were compared between the two groups. LLR was performed in 75 of the 217 included patients. After PSM, 72 patients with well-balanced baseline levels were enrolled into each group. Although the operative time was significantly longer in the LLR group than in the OLR group (median, 237.5 vs. 210 min, P = 0.024), the intraoperative blood loss was significantly less in the LLR group than in the OLR group (median, 200 vs. 350 ml, P = 0.005). Patients in the LLR group had fewer complications than those in the OLR group (P = 0.035). Furthermore, overall survival (OS, P = 0.827) and recurrence-free survival (RFS, P = 0.694) were comparable between the two groups. LLR for resectable HCC patients with BCLC stage B is safe and feasible in carefully selected patients and has superior perioperative outcomes and similar survival rates compared with OLR.

Does laparoscopic hepatectomy offer benefits for patients with COPD? A propensity score analysis

BACKGROUND

To date, it remains unclear whether laparoscopic hepatectomy (LH) is safe and feasible for patients with chronic obstructive pulmonary disease (COPD). Thus, we compared the perioperative outcomes of LH versus open hepatectomy (OH) in this special cohort of patients.

METHODS

Between February 2014 and October 2020, 162 patients who underwent hepatectomy met the inclusion and exclusion criteria of this study. Perioperative data were compared between the two groups by propensity score matching (PSM) analysis.

RESULTS

After PSM, 55 patients with well-balanced baseline data were included in each group. Intraoperative blood loss, overall postoperative complications, and postoperative pulmonary complications (PPCs) were significantly lower in the LH group than in the OH group (P < 0.001, P = 0.047, and P = 0.020 after PSM, respectively). However, major complications, early readmission, and early mortality were comparable between the two groups. According to multivariate analysis, high stage of COPD, preoperative tobacco use, and long operative time were independent risk factors for PPCs, whereas treatment with LH was a protective factor.

CONCLUSION

LH is safe and feasible for selected patients with COPD when performed by experienced surgeons, and it has superior perioperative outcomes (especially regarding PPCs) when compared to OH.

LigaSure versus monopolar cautery for recipient hepatectomy in liver transplantation: a propensity score-matched analysis

Background

Recipient hepatectomy during liver transplantation (LT) is one of the most challenging aspects of surgery due to the possibility of massive bleeding. This study aimed to compare and analyze the effectiveness between LigaSure and monopolar cautery in recipients.

Methods

We reviewed 187 recipients who underwent LT from March 2019 to June 2020. We compared the surgical outcomes of the 69 recipients who underwent recipient hepatectomy with LigaSure (LigaSure group) and 118 recipients who underwent with monopolar cautery. Propensity score matching (PSM) was performed using the nearest-neighbor method at a ratio of 1:1 based on 14 baseline characteristics and possible factors that influence postoperative bleeding.

Results

A total of 187 adult recipients were reviewed retrospectively. In the propensity score-matched analysis, The rates of bleeding and infectious complication were significantly lower in the LigaSure group than in the monopolar cautery group (3/69, 4.35% versus 13/69, 18.8%; P=0.015 and 1/69, 1.45% versus 9/69, 13.0%; P=0.017). The length of postoperative hospital stay was shorter in the LigaSure group (mean: 23.1±16.1 versus 39.6±58.2 days; P=0.024).

Conclusions

Recipient hepatectomy with LigaSure is associated with a short hospital stay due to low re-operation rates, postoperative bleeding, and secondary infection related to bleeding.

Clinical benefits of vessel sealing system (LigaSure™) during surgery for soft tissue sarcoma: a propensity score matching analysis

BACKGROUND

Soft tissue sarcomas arise in the deep sites of the buttocks and lower extremities. Since a tourniquet is not applied during surgery for soft tissue sarcomas at such sites, excessive intraoperative blood loss may occur. Various devices, including LigaSure™ (Medtronic, Dublin, Ireland), are used as electrothermal bipolar vessel sealers. However, its clinical relevance in soft tissue sarcomas surgery remains unclear. This study aimed to assess the effectiveness of LigaSure™ in soft tissue sarcomas surgery.

METHODS

This study included 168 patients who underwent surgeries for soft tissue sarcomas in the deep sites in the buttocks and lower extremities between January 2004 and March 2018. The primary outcome was intraoperative blood loss, and secondary outcomes were surgery duration, wound complications, perioperative haemoglobin concentrations and intraoperative blood transfusion. To reduce selection biases, propensity score matching was applied. We defined the matched cases wherein LigaSure™ was used as the 'using group' and the other matched cases as the 'non-using group'. Outcomes were compared between both groups.

RESULTS

From each group, 35 cases were selected using propensity score matching. The intraoperative blood loss was significantly smaller statistically in the using group (181.5 ± 240.4 ml vs. 394.7 ± 547.3 ml, respectively; P = 0.041). The duration of operation was longer in the using group (189.9 ± 97.6 min vs. 140.6 ± 75.7 min, respectively; P = 0.007). There were no significant differences in other outcomes.

CONCLUSION

By using LigaSure™ for soft tissue sarcomas occurring in the buttocks and lower extremities, we observed a trade-off between reduced intraoperative blood loss and longer operative time.

Patterns, timing, and predictors of recurrence after laparoscopic liver resection for hepatocellular carcinoma: results from a high-volume HPB center

Background

Although long-term outcomes may be comparable between laparoscopic liver resection (LLR) and open liver resection (OLR) for hepatocellular carcinoma (HCC), there has been little discussion regarding the patterns of recurrence after LLR.

Methods

Patients with HCC who underwent hepatectomy between April 2015 and November 2018 were included in this study. The recurrence patterns were analyzed in detail. The recurrence outcomes following laparoscopic versus OLR for HCC were compared after 1:2 propensity score matching. Potential risk factors for recurrence were also assessed with Cox proportional risk models.

Results

Among 425 patients after LLR, 144 (33.8%) experienced recurrence at the last follow-up, with a median recurrence-free survival (RFS) of 10.0 months (range 1–58 months). The most frequent recurrence site was the liver (n = 99, 68.8%), followed by the surgical margin (n = 15, 10.4%) and distant metastases (n = 12, 8.3%). Liver recurrence with distant metastasis (n = 10, 6.9%) tended to occur early (median 8.0 months), while peritoneal recurrence (n = 8, 5.6%) occurred later (median 14.0 months). A total of 120 (83.3%) patients had recurrence within 2 years after LLR. No trocar site recurrence was observed in this study. The recurrence patterns, timing, and treatment did not show significant differences between the LLR and OLR. The independent risk factors for recurrence included ALBI grade, postoperative α-fetoprotein > 8 ng/ml, tumor size > 5 cm, surgical margin ≤ 1 cm, and multiple tumors. Patients with recurrence had 1- and 5-year overall survival rates of 81.1% and 60.7%, respectively, compared with rates of 95.8% and 92.9% for patients without recurrence (P < 0.000).

Conclusion

This study suggested that intrahepatic recurrence was still the most common recurrence pattern for HCC after LLR and that LLR did not increase the risk of trocar hole recurrence or implantation. Most cases of recurrence occurred within 2 years after LLR, suggesting that surveillance should be targeted to early recurrence.

Supplementary Information

The online version of this article (10.1007/s00464-021-08390-5) contains supplementary material, which is available to authorized users.

Changing trends in hepatocellular carcinoma management: Results from a nationwide database in the last decade

OBJECTIVE

The therapeutic strategies for hepatocellular carcinoma (HCC) have greatly expanded in recent years. However, the actual usage of each of these treatments in clinical routine remains unknown. Here, we analysed the distribution and changes of the main surgical and radiological therapeutic procedures nationwide during the last decade.

METHODS

Retrospectively, analysis of the data on all >18-year-old patients with a diagnosis of HCC identified in the French Program for the Medicalization of Information Systems database that contains all discharge summaries from all French hospitals. The number and percentage of the therapeutic procedures performed from January 2010 to December 2019 were extracted.

RESULTS

A total of 68,416 therapeutic procedures were performed in 34,000 HCC patients. Whereas HCC incidence remained stable, the annual number of procedures frankly increased over the decade (from 4267 to 8042). Trans-arterial chemoembolization was the most frequently performed technical procedure, with a double-digit annual growth from 2010 (n = 1932) to 2015 (n = 4085), before stabilization from 2016. Selective internal radiation therapy displayed the highest increase in the decade (+475%). Among curative treatments, the annual number of percutaneous tumour ablations more than doubled in 10 years, till representing 64% of curative treatments in cirrhotic patients in 2019. Surgical tumour resections showed a 1.5-fold increase in 10 years, due to the great increase in minimally invasive approaches, whereas the proportion of open resection progressively decreased.

CONCLUSION

Minimally invasive procedures have gained major importance in HCC management during the last decade. Percutaneous thermal ablation has emerged as the first curative treatment performed for patients with HCC.

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.

Soft tissue sarcoma at the adductor compartment of the thigh may have a greater risk of tumor-associated events and wound complications

PURPOSE

Soft tissue sarcomas (STSs) of the thigh's adductor compartment frequently attain a large size before clinical presentation and displace the major neurovascular and lymph structures. We aimed to elucidate the clinical outcome in patients with STS of the thigh's adductor compartment.

PATIENTS AND METHODS

From March 1999 to June 2016, we treated 24 adult patients with primary STS of the thigh's adductor compartment.

RESULTS

The mean age at diagnosis was 60 years. There were 13 men and 11 women. The mean follow-up period after the date of the initial treatment was 84 months. The mean tumor size at diagnosis was 13.6 cm. The disease-specific survival was 75.3% at 5 years. Local recurrence was detected in seven patients. The 5-year local recurrence-free rate was 69.9%. The patients with proximal STS had significantly poorer local control, compared to the remaining patients. Twelve (50%) patients developed 14 surgical wound complications. Complications included wound dehiscence ( n = 7), infections ( n = 6), lymphorrhea ( n = 1), wound dehiscence and infection ( n = 1), and infection and lymphorrhea ( n = 1). Six patients underwent additional surgical treatment. Intraoperative blood loss and operative time were related to the incidence of wound complications. Intraoperative blood loss and operative time in patients with proximal adductor STS were significantly larger than those in the remaining patients.

CONCLUSION

We should take care of patients with STS of the thigh's adductor compartment, especially for proximal adductor STS, because they have a greater risk of local recurrence and wound complications.

Is laparoscopic liver resection suitable for selected patients with BCLC stage B HCC? A propensity score-matched analysis

BACKGROUND

The optimal treatment for patients with Barcelona Clinic Liver Cancer (BCLC) stage B hepatocellular carcinoma (HCC) is controversial given the variability of tumour status within this group of patients. This aim of this study was to compare the outcomes of laparoscopic liver resection (LLR) to transarterial chemoembolization (TACE) in a subset of selected patients with BCLC stage B HCC.

METHODS

Patients with resectable BCLC stage B HCC who underwent treatment between April 2015 and October 2018 were identified for further analysis. Propensity score matching (PSM) was conducted to minimize effect of confounding factors. Perioperative and long-term outcomes were compared between the two groups and multivariate analysis was performed to identify risk factors related to the overall survival (OS).

RESULTS

From a total of 224 patients 70 were included into each group after PSM. The overall and major morbidity were comparable between the LLR and TACE groups (P = 0.700 and P = 0.500 after PSM, respectively). The OS in LLR group was significantly better than that in the TACE group (P < 0.001). Tumor number ≥4, the diameter of the biggest tumor >5 cm, and patients who underwent TACE were independent predictors of poorer OS.

CONCLUSIONS

LLR for selected patients with BCLC stage B HCC is safe and feasible and has improved survival as compared to TACE.

Laparoscopically anatomical versus non-anatomical liver resection for large hepatocellular carcinoma

BACKGROUND

The role of laparoscopically anatomical resection (LAR) for hepatocellular carcinoma (HCC) remains unclear due to the more demanding technique required in laparoscopy. This study is to analyze the clinical impact of LAR compared to laparoscopically non-anatomical resection (LNAR) for HCC.

METHODS

All patients received laparoscopic hepatectomy for HCC (diameter 5-10 cm) from January 2015 to December 2018 were retrospectively enrolled in this study. Patients were divided into LAR and LNAR groups. The perioperative and oncological outcomes were evaluated based on propensity score matching (PSM) method.

RESULTS

After PSM, 51 patients in each group were enrolled. The operative time in LAR group was longer (240 vs 195.0 min, p = 0.012) and blood loss was more (200.0 vs 150.0 mL, p = 0.030) than those of LNAR group, respectively. The total complication rates were comparable between them (21.6% vs 17.6%, p = 0.500). The 3-year overall survival rates were 59.4% in LAR group and 38.7% in LNAR group, respectively (p = 0.045). The 3-year disease-free survival rates were 52.3% in LAR group and 27.0% in LNAR group, respectively (p = 0.042).

CONCLUSION

LAR could be feasibly performed with comparable perioperative outcomes and contributed to improve long-term survival in patients with HCC (diameter 5-10 cm) when compared to LNAR.

The Extrahepatic Glissonian Versus Hilar Dissection Approach for Laparoscopic Formal Right and Left Hepatectomies in Patients with Hepatocellular Carcinoma

BACKGROUND

Few studies have been performed to evaluate the value of the Glissonian approach (GA) for laparoscopic formal hemihepatectomy. The purpose of this study was to compare the outcomes of extrahepatic GA with those of the conventional hilar dissection approach for laparoscopic formal right and left hepatectomies in patients with hepatocellular carcinoma (HCC).

METHODS

Between January 2015 and October 2017, a total of 95 HCC patients who underwent pure laparoscopic formal hemihepatectomies, of whom 49 underwent the GA, were included in this study. After a 1:1 propensity score matching, 42 laparoscopic GA hepatectomies were compared to 42 conventional approach (CA) hepatectomies. We have analyzed perioperative and oncologic outcomes of the two different operative approaches for HCC treatments.

RESULTS

The GA did not increase the postoperative overall complication rates (P = 0.415) or the mean comprehensive complication index (P = 0.414) when compared with the CA. However, the operative time was significantly shorter (P = 0.006), and intraoperative blood loss was significantly lower (P < 0.001) in the GA group than in the CA group. There were no significant differences between the GA and CA groups regarding 3-year overall survival rate (P = 0.765) or 3-year disease-free survival rate (P = 0.622).

CONCLUSIONS

Pure laparoscopic extrahepatic GA hemihepatectomy is safe and feasible, and it was associated with similar complication rates and equivalent 3-year survival outcomes compared to the conventional approach in selected patients with HCC.

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

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

Outcomes of laparoscopic repeat liver resection for recurrent liver cancer: A system review and meta-analysis

BACKGROUND

With the improvements of surgical instruments and surgeons' experience, laparoscopic liver resection has been applied for recurrent tumors. However, the value of laparoscopic repeat liver resection (LRLR) is still controversial nowadays, which compelled us to conduct this meta-analysis to provide a comprehensive evidence about the efficacy of LRLR for recurrent liver cancer.

METHODS

A computerized search was performed to identify all eligible trials published up to April 2019. This meta-analysis was conducted to estimate the perioperative data and oncological outcomes of LRLR by compared with open repeat liver resection (ORLR) and laparoscopic primary liver resection (LPLR). A fixed or random-effect modal was established to collect the data.

RESULTS

A total of 1232 patients were included in this meta-analysis (LRLR: n = 364; ORLR: n = 396; LPLR: n = 472). LRLR did not increase the operative time compared to ORLR (WMD = 15.92 min; 95%CI: -33.53 to 65.37; P = .53). Conversely, LRLR for patients with recurrent tumors was associated with less intraoperative blood loss (WMD = -187.33 mL; 95%CI: -249.62 to -125.02; P < .00001), lower transfusion requirement (OR = 0.24; 95%CI: 0.06-1.03; P = .05), fewer major complications (OR = 0.42; 95%CI: 0.23-0.76; P = .004), and shorter hospital stays (WMD = -2.31; 95%CI: -3.55 to -1.07; P = .0003). In addition, the oncological outcomes were comparable between the two groups. However, as for the safety of LRLR compared with LPLR, although the operative time in LRLR group was longer than LPLR group (WMD = 58.63 min; 95%CI: 2.99-114.27; P = .04), the blood loss, transfusion rates, R0 resection, conversion, postoperative complications, and mortality were similar between the two groups.

CONCLUSIONS

LRLR for recurrent liver cancer could be safe and feasible in selected patients when performed by experienced surgeons.

Outcomes of Laparoscopic Liver Resection for Patients with Multiple Hepatocellular Carcinomas Meeting the Milan Criteria: A Propensity Score-Matched Analysis

Background: Until now, there is little knowledge about the value of laparoscopic liver resection (LLR) for patients with multiple hepatocellular carcinomas (HCC). This study was performed to assess the efficacy and outcomes of LLR versus open liver resection (OLR) for patients with multiple HCC meeting the Milan criteria.

Methods: One hundred fifteen patients with multiple HCC meeting the Milan criteria who underwent liver resection from April 2015 to March 2018 were enrolled into this study. According to the different surgical procedures, patients were divided into LLR group and OLR group. Perioperative and oncological outcomes were compared between the two groups after propensity score matching (PSM) with 1:1 match.

Results: Thirty three patients were included into each group after PSM with well-balanced basic level. The intraoperative blood loss in LLR group was less than OLR group before PSM (median, 200 vs. 300 mL, P = .004), but the difference was not statistically significant after PSM (median, 200 vs. 300 mL, P = .064). LLR group showed shorter postoperative hospital stay when compared with OLR group (median, 7 vs. 8 days, respectively, P = .014). The perioperative complications and early mortality were comparable in both groups. There were no significant differences in the term of overall survival (OS. P = .502) or recurrence-free survival (RFS. P = .887) between the two groups after PSM.

Conclusions: LLR could be safely and feasibly performed for patients with multiple HCC meeting the Milan criteria in selected patients. It does not increase the risks of postoperative complications and has a similar oncological outcomes compared to OLR.

Comparison of Outcomes Between Open Major Hepatectomy Using CUSA and Laparoscopic Major Hepatectomy Using "Lotus" Liver Blade. A Propensity Score Matched Analysis

Introduction: Evolution in laparoscopic liver surgery during the past two decades is an indisputable fact. According to the second international consensus conference for laparoscopic liver resection held in Morioka, Japan in 2014 major resections are still regarded as innovative procedures in the exploration phase. On this basis, our study aims to explore the efficacy and safety of laparoscopic vs. open major liver resection and therefore increase the existing evidence on major laparoscopic liver surgery. Methods: All consecutive patients who underwent major liver resection, open and laparoscopic from January 2016 to May 2018 were identified from our prospectively maintained database. Propensity score matching analysis was performed using R statistical tool in SPSS to isolate matched open and laparoscopic cases which were compared for intraoperative and postoperative short-term outcomes. Lotus ultrasonic energy device was used for parenchymal transection in laparoscopic cases vs. CUSA in open procedures. Results: Propensity score matching analysis was performed on 82 consecutive patients (61 open and 21 laparoscopic major hepatectomies) resulting in 40 matched patients, 20 in each group. The mean total duration of surgery and duration of parenchymal transection were slightly longer in the laparoscopic group (p = 0.419, p = 0.348). There was no difference in the intraoperative and postoperative transfusion rates. Patients after laparoscopic surgery were discharged 2 days earlier on average (p = 0.310). No difference was observed in complication rates and mortality. Conclusion: Our data did not reveal inferiority of the laparoscopic major hepatectomy vs. the open approach in any parameter compared. The use of the Lotus ultrasonic energy device appeared to be efficient and safe for parenchymal transection in the laparoscopic procedures.

Disparities in elective surgery for diverticulitis: Identifying the gap in care

BACKGROUND

Minimally invasive surgery (MIS) in patients with diverticulitis is advantageous relative to open surgery. We aimed to determine disparities associated with MIS access for diverticulitis and post-operative complications.

METHODS

The Florida Inpatient Discharge Dataset was retrospectively queried for patients with diverticulitis undergoing elective surgery between 2013 and 2015. Associations of patient, physician, and hospital characteristics with surgical approach (MIS vs open) and development of complications were calculated in two separate mixed effects logistic regression models.

RESULTS

Of the 5857 patients in the analysis, older, sicker patients, residing in rural areas or with Medicaid insurance had decreased odds of receiving MIS. Being treated by high volume or colorectal surgeons increased the odds of MIS. Decreased complications were present with MIS, in younger, healthier patients, treated by high volume surgeons.

CONCLUSIONS

Disparities in Florida are present in patients undergoing elective diverticulitis surgery. MIS access and complications rates are not equal, and MIS is associated with significantly reduced odds of post-operative complications. Improved access to MIS-trained surgeons is a critical step towards improving surgical outcomes for Floridians.

Surgical outcomes and quality of life between laparoscopic and open approach for hepatic hemangioma: A propensity score matching analysis

The main objective of the study was to compare the surgical outcomes and quality of life (QOL) of patients with hepatic hemangioma either by laparoscopic or open surgery using a propensity score analysis.We retrospectively reviewed patients with hepatic hemangioma undergoing laparoscopic liver surgery (LLS) or open liver surgery (OLS) between January 2016 and December 2017. Intraoperative and postoperative characteristics, and quality of life, according to Short Form-36 Healthy Survey (SF-36) questionnaire, were compared between groups. We performed 1:1 propensity score matching (PSM) between the LLS and OLS groups.A total of 205 patients who involved in the analysis (80 LLS vs 125 OLS) were matched (1:1) by age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) score, previous upper abdominal surgery, comorbidities, operation method, type of resection, tumor localization, size, and number. After PSM, 73 well-matched patients in each group were obtained. LLS was associated with significantly less blood loss, shorter postoperative hospital stay and fewer complications. The QOL scores weren't significantly different between the 2 groups, though the LLS group tended to be superior to the OLS group in terms of bodily pain (BP) and mental health (MH) at 3 months after surgery.In comparison with the conventional open approach, laparoscopic liver surgery for hepatic hemangioma appears to have improved short-term surgical outcomes and comparable QOL in selected patients.

Stapleless laparoscopic left lateral sectionectomy for hepatocellular carcinoma: reappraisal of the Louisville statement by a young liver surgeon

BACKGROUND

Laparoscopic liver resection has been regarded as the standard treatment for liver tumors located at the left lateral liver sector. However, few studies have reported the results of laparoscopic left lateral sectionectomy (LLS) for HCC, not to mention the feasibility of this emerging technique for the less experienced liver surgeons. The current study would reappraise the Louisville statement by examining the outcome of LLS performed by a young liver surgeon.

METHODS

We retrospectively reviewed two separate groups of patients who underwent open or laparoscopic left lateral sectionectomies at Chung Gung Memorial Hospital, Linkou. All laparoscopic hepatectomies were performed by the index young surgeon following a stepwise stapleless LLS. The surgical results and oncological outcomes of laparoscopic vs. open hepatectomies (LH and OH, respectively) with the surgical indication of HCC at left lateral liver sector were further compared and analyzed.

RESULTS

18 of 29 patients in the laparoscopic group and 75 patients in the conventional open group had primary HCC. The demographic data was essentially the same for the two groups. Statistical analysis revealed that the LH group had smaller tumor size, higher blood transfusion requirement, longer duration of inflow control and parenchymal transection, and longer operation time. However, no significant difference was observed in terms of complication rate, mortality rate, and hospital stay between the two groups. After adjusting for tumor size, LH and OH showed no statistical difference in the amount of blood transfusion, operation time and patient survival.

CONCLUSIONS

This study demonstrated that stapleless LLS is a safe and feasible procedure for less experienced liver surgeons to resect HCC located at the left lateral liver sector. This stepwise stapleless LSS can not only achieve surgical results comparable to OH but also can provide a platform for liver surgeons to apply laparoscopic technique before conducting more complicated liver resections.

Outcomes of pure laparoscopic Glissonian pedicle approach hepatectomy for hepatocellular carcinoma: a propensity score matching analysis

BACKGROUND

Few studies had been performed to concern the outcomes of pure laparoscopic Glissonian pedicle approach hepatectomy (LGAH) for hepatocellular carcinoma (HCC). The aim of this study was to compare the outcomes of LGAH versus open Glissonian pedicle approach hepatectomy (OGAH) for HCC, especially in patients with cirrhosis.

METHODS

Hepatocellular carcinoma patients who underwent pure LGAH and OGAH between January 2015 and July 2017 in our institution were retrospectively enrolled in this study. Propensity score matching (PSM) of patients in a ratio of 1:1 was conducted to adjust the known confounders. The perioperative and oncological outcomes were compared between the two groups after PSM.

RESULTS

Some 80 patients underwent pure LGAH and 134 had OGAH. After PSM, 67 patients in each group were well matched for analysis. Both the postoperative overall complication rates (13.4% vs. 29.9%, P = 0.021) and mean comprehensive complication index (2.63 vs. 7.40, P = 0.035) were significantly lower in the LGAH group than those in OGAH group. Although the operative time was longer in the LRH group (P < 0.001), the length of postoperative hospital stay was shorter in the LRH group (P = 0.024). Furthermore, both the 3-year overall survival rate (73.3% for LGAH vs. 77.8% for OGAH, P = 0.338) and 3-year disease-free survival rate (56.4% for LGAH vs. 62.5% for OGAH, P = 0.455) were not significantly different between the groups.

CONCLUSION

Pure laparoscopic Glissonian approach may be a better alternative to open Glissonian approach in selected HCC patients, which provided fewer complications, shorter postoperative hospital stay and comparable oncological outcomes.