External validation of different difficulty scoring systems of laparoscopic liver resection for hepatocellular carcinoma

Comparison of clinical outcome between laparoscopic and open hepatectomy of high difficulty score for hepatocellular carcinoma: a propensity score analysis

BACKGROUND

Laparoscopic liver resection (LLR) of high difficulty score is technically challenging. There is a lack of clinical evidence to support its applicability in terms of the long-term survival benefits. This study aims to compare clinical outcomes between LLR and the open liver resection of high difficulty score for hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

From 2010 to 2020, using Iwate criteria, 424 patients underwent liver resection of high difficulty score by the laparoscopic (n = 65) or open (n = 359) approach. Propensity score (PS) matching was performed between the two groups. Short-term and long-term outcomes were compared between PS-matched groups. Univariate and multivariate analyses were performed to identify prognostic factors affecting survival.

RESULTS

The laparoscopic group had significantly fewer severe complications (3% vs. 10.8%), and shorter median hospital stays (6 days vs. 8 days) than the open group. Meanwhile, the long-term oncological outcomes were comparable between the two groups, in terms of the tumor recurrence rate (40% vs. 46.1%), the 5-year overall survival rate (75.4% vs. 76.2%), and the 5-year recurrence-free survival rate (50.3% vs. 53.5%). The high preoperative serum alpha-fetoprotein level, multiple tumors, and severe postoperative complications were the independent poor prognostic factors associated with worse overall survival. The surgical approach (Laparoscopic vs. Open) did not influence the survival.

CONCLUSION

LLR of high difficulty score for selected patients with HCC has better short-term outcomes than the open approach. More importantly, it can achieve similar long-term survival outcomes as the open approach.

Risk Factors and Long-Term Implications of Unplanned Conversion During Laparoscopic Liver Resection for Hepatocellular Carcinoma

Background: Laparoscopic liver resection (LLR) has become a widely used standardized operation for patients with hepatocellular carcinoma (HCC) in the field of hepatic surgery. However, the risk factors and long-term implications associated with unplanned conversion to an open procedure during the LLR have not been adequately studied. Methods: The study incorporated 96 patients with HCC. Risk factors of conversion and their prognosis were analyzed by comparing patients who successfully underwent LLR with those who required unplanned conversion. Results: In this study, the unplanned conversion rate for laparoscopic hepatectomy was 42.7%. Patients who underwent conversion had longer length of stay (8 versus 7 days, P < .001), longer operation time (297.73 versus 194.03 minutes, P = .000), a higher transfusion rate (29.3% versus 5.5%, P < .001), and more postoperative complications compared with patients who successfully underwent LLR. The two surgical maneuvers did not show substantial disparities in terms of total survival and disease-free survival rates. Risk factors of unplanned conversion contained tumor location (odds ratio [OR], 3.129; 95% confidence interval [CI]: 1.214-8.066; P = 0.018) and tumor size (OR, 2.652; 95% CI: 1.039-6.767; P = 0.041). Conclusions: The unplanned conversion during LLR for HCC was linked to unfavorable short-term prognosis, yet it did not influence long-term oncologic outcomes. Moreover, preoperative evaluation of tumor size and location may effectively reduce the probability of unplanned conversion during LLR.

Sub-classification of laparoscopic left hepatectomy based on hierarchic interaction of tumor location and size with perioperative outcomes

BACKGROUND

The aim of this multicentric study was to investigate the impact of tumor location and size on the difficulty of Laparoscopic-Left Hepatectomy (L-LH).

METHODS

Patients who underwent L-LH performed across 46 centers from 2004 to 2020 were analyzed. Of 1236 L-LH, 770 patients met the study criteria. Baseline clinical and surgical characteristics with a potential impact on LLR were included in a multi-label conditional interference tree. Tumor size cut-off was algorithmically determined.

RESULTS

Patients were stratified into 3 groups based on tumor location and dimension: 457 in antero-lateral location (Group 1), 144 in postero-superior segment (4a) with tumor size ≤40 mm (Group 2), and 169 in postero-superior segment (4a) with tumor size >40 mm (Group 3). Patients in the Group 3 had higher conversion rate (7.0% vs. 7.6% vs. 13.0%, p-value .048), longer operating time (median, 240 min vs. 285 min vs. 286 min, p-value <.001), greater blood loss (median, 150 mL vs. 200 mL vs. 250 mL, p-value <.001) and higher intraoperative blood transfusion rate (5.7% vs. 5.6% vs. 11.3%, p-value .039). Pringle's maneuver was also utilized more frequently in Group 3 (66.7%), compared to Group 1 (53.2%) and Group 2 (51.8%) (p = .006). There were no significant differences in postoperative stay, major morbidity, and mortality between the three groups.

CONCLUSION

L-LH for tumors that are >40 mm in diameter and located in PS Segment 4a are associated with the highest degree of technical difficulty. However, post-operative outcomes were not different from L-LH of smaller tumors located in PS segments, or tumors located in the antero-lateral segments.

Conversion of Minimally Invasive Liver Resection for HCC in Advanced Cirrhosis: Clinical Impact and Role of Difficulty Scoring Systems

BACKGROUND

Minimally invasive liver resections (MILRs) in cirrhosis are at risk of conversion since cirrhosis and complexity, which can be estimated by scoring systems, are both independent factors for. We aimed to investigate the consequence of conversion of MILR for hepatocellular carcinoma in advanced cirrhosis.

METHODS

After retrospective review, MILRs for HCC were divided into preserved liver function (Cohort-A) and advanced cirrhosis cohorts (Cohort-B). Completed and converted MILRs were compared (Compl-A vs. Conv-A and Compl-B vs. Conv-B); then, converted patients were compared (Conv-A vs. Conv-B) as whole cohorts and after stratification for MILR difficulty using Iwate criteria.

RESULTS

637 MILRs were studied (474 Cohort-A, 163 Cohort-B). Conv-A MILRs had worse outcomes than Compl-A: more blood loss; higher incidence of transfusions, morbidity, grade 2 complications, ascites, liver failure and longer hospitalization. Conv-B MILRs exhibited the same worse perioperative outcomes than Compl-B and also higher incidence of grade 1 complications. Conv-A and Conv-B outcomes of low difficulty MILRs resulted in similar perioperative outcomes, whereas the comparison of more difficult converted MILRs (intermediate/advanced/expert) resulted in several worse perioperative outcomes for patients with advanced cirrhosis. However, Conv-A and Conv-B outcomes were not significantly different in the whole cohort where "advanced/expert" MILRs were 33.1% and 5.5% in Cohort A and B.

CONCLUSIONS

Conversion in the setting of advanced cirrhosis can be associated with non-inferior outcomes compared to compensated cirrhosis, provided careful patient selection is applied (patients elected to low difficulty MILRs). Difficulty scoring systems may help in identifying the most appropriate candidates.

The difficulty grade of laparoscopic hepatectomy for hepatocellular carcinoma correlates with long-term outcomes

The tremendous development of laparoscopic hepatectomy helps to relieve the difficulties encountered during open hepatectomy. Therefore, a difficulty scoring system was produced to assess the difficulty grade of laparoscopic hepatectomy. The aim of this study was to explore whether the IWATE-DSS is comparable to the long-term outcomes of LH for hepatocellular carcinoma. Clinical data from all consecutive patients who underwent laparoscopic hepatectomy for hepatocellular carcinoma at the Sir Run Run Shaw Hospital, Hangzhou, were prospectively collected and reviewed. The difficulty level of the operations was graded using the IWATE-DSS. The perioperative and postoperative outcomes of laparoscopic hepatectomy were compared at each difficulty level. A total of 300 patients underwent laparoscopic hepatectomy for HCC during the study period. The perioperative and postoperative outcomes were significantly different between the groups according to the IWATE-DSS. There were significant differences in both the intraoperative (bleeding control p = 0.000; surgical time p = 0.000; estimated blood loss p = 0.033) and postoperative variables (postoperative hospital stay p = 0.005) among these four groups. The 5-year disease-free survival decreased significantly along with the LH difficulty score (p = 0.000). The 5-year overall survival also decreased significantly along with the LH difficulty score (p = 0.000). IWATE-DSS was significantly correlated with short- and long-term outcomes in patients who underwent laparoscopic hepatectomy for HCC.

Conditional cumulative incidence of postoperative complications stratified by complexity classification for laparoscopic liver resection: Optimization of in-hospital observation

BACKGROUND

The optimal in-hospital observation periods associated with minimal risks of complications and unplanned readmission after laparoscopic liver resection are unknown. The purpose of this study was to assess changes in the risks of postoperative complications over time.

METHODS

Surgical complexity of laparoscopic liver resection was stratified into grades I (low complexity), II (intermediate), and III (high) using our 3-level complexity classification. The cumulative incidence rate and conditional probability of postoperative complication and risk factors for complication Clavien-Dindo grade ≥II (defined as treatment-requiring complications) were assessed.

RESULTS

The cumulative incidence of treatment-requiring complications was higher in patients undergoing grade III resection than in patients undergoing grade I resection (32.3% vs 10.4%, P < .001) and grade II resection (32.3% vs 20.7%, P = .019). The conditional probability of postoperative complication stratified by our complexity classification decreased over time and was <10% for patients undergoing grade I resection on postoperative day 1, grade II resection on postoperative day 4, and grade III resection on postoperative day 10.

CONCLUSION

The conditional cumulative incidence of treatment-requiring complications for patients undergoing laparoscopic liver resection is well stratified based on the 3-level complexity classification. Conditional complication risk analysis stratified by the 3 complexity grades may be useful for optimizing in-hospital observation after laparoscopic liver resection.