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Combari-Ancellin P, Nakada S, Savier É, Golse N, Faron M, Lim C, Vibert É, Cherqui D, Scatton O, Goumard C. Initial laparoscopic liver resection is associated with reduced adhesions and transfusions at the time of salvage liver transplantation. HPB (Oxford) 2024:S1365-182X(24)01767-2. [PMID: 38944570 DOI: 10.1016/j.hpb.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 06/04/2024] [Accepted: 06/07/2024] [Indexed: 07/01/2024]
Abstract
BACKGROUND Laparoscopic liver resection (LLR) has been associated with improved patient recovery as well as reduced postoperative adhesions compared to open LR (OLR) and could therefore facilitate redo liver surgery. LLR prior to liver transplantation (LT) is increasingly performed, LT being saved for HCC recurrence. LT is still performed by open surgery due to vascular reconstructions and underlying liver chronic disease. We evaluated the impact of laparoscopic approach for LR prior to LT in terms of intraoperative transfusions, adhesions severity and outcome. METHODS Data from all patients who underwent a LT after LR in two French high-volume tertiary centers were retrospectively reviewed. The impact of LLR on per operative and postoperative outcome was assessed using logistic regression. RESULTS 170 patients were included, 43 patients in the LLR group and 127 in the OLR group. Preoperative characteristics were comparable between both groups, except LLR group included more patients with "very early-stage" BCLC tumors than OLR group (51% vs. 33%, p = 0.02) and less anatomical resections (54% vs. 75%, p = 0.015). During LT, the transfusion rate was significantly higher in the OLR group (71.4% vs 44.2%, p = 0.002) as well as the proportion of type III adhesions according to OLSG classification (p < 0.001). Multivariate analysis found LLR to be an independent protective factor for adhesions and transfusion (p = 0.001 and p = 0.03 respectively). CONCLUSION Laparoscopic liver resection was associated with reduced postoperative adhesions and transfusion requirements during subsequent liver transplantation.
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Affiliation(s)
- Prisca Combari-Ancellin
- Department of Hepatobiliary Surgery and Liver Transplantation, Sorbonne University, Hôpital Pitié-Salpêtrière, Assistance Publique- Hôpitaux de Paris, France
| | - Shinichiro Nakada
- Centre Hépato-Biliaire, Université Paris- Sud, Hôpital Paul Brousse, Villejuif, France
| | - Éric Savier
- Department of Hepatobiliary Surgery and Liver Transplantation, Sorbonne University, Hôpital Pitié-Salpêtrière, Assistance Publique- Hôpitaux de Paris, France
| | - Nicolas Golse
- Centre Hépato-Biliaire, Université Paris- Sud, Hôpital Paul Brousse, Villejuif, France
| | - Matthieu Faron
- Department de Chirurgie Oncologique, Gustave Roussy Cancer Campus, Villejuif, INSERM 1018, Equipe Oncostat, Université Paris Saclay, Gif-sur-Yvette, France
| | - Chetana Lim
- Department of Hepatobiliary Surgery and Liver Transplantation, Sorbonne University, Hôpital Pitié-Salpêtrière, Assistance Publique- Hôpitaux de Paris, France
| | - Éric Vibert
- Centre Hépato-Biliaire, Université Paris- Sud, Hôpital Paul Brousse, Villejuif, France
| | - Daniel Cherqui
- Centre Hépato-Biliaire, Université Paris- Sud, Hôpital Paul Brousse, Villejuif, France
| | - Olivier Scatton
- Department of Hepatobiliary Surgery and Liver Transplantation, Sorbonne University, Hôpital Pitié-Salpêtrière, Assistance Publique- Hôpitaux de Paris, France
| | - Claire Goumard
- Department of Hepatobiliary Surgery and Liver Transplantation, Sorbonne University, Hôpital Pitié-Salpêtrière, Assistance Publique- Hôpitaux de Paris, France.
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Vitale A, Angelico R, Sensi B, Lai Q, Kauffmann E, Scalera I, Serenari M, Ginesini M, Romano P, Furlanetto A, D'Amico F. What Is the Role of Minimally Invasive Liver Surgery in Treating Patients with Hepatocellular Carcinoma on Cirrhosis? Cancers (Basel) 2024; 16:966. [PMID: 38473327 DOI: 10.3390/cancers16050966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 02/24/2024] [Accepted: 02/25/2024] [Indexed: 03/14/2024] Open
Abstract
Minimally invasive liver surgery (MILS) has been slowly introduced in the past two decades and today represents a major weapon in the fight against HCC, for several reasons. This narrative review conveys the major emerging concepts in the field. The rise in metabolic-associated steatotic liver disease (MASLD)-related HCC means that patients with significant cardiovascular risk will benefit more profoundly from MILS. The advent of efficacious therapy is leading to conversion from non-resectable to resectable cases, and therefore more patients will be able to undergo MILS. In fact, resection outcomes with MILS are superior compared to open surgery both in the short and long term. Furthermore, indications to surgery may be further expanded by its use in Child B7 patients and by the use of laparoscopic ablation, a curative technique, instead of trans-arterial approaches in cases not amenable to radiofrequency. Therefore, in a promising new approach, multi-parametric treatment hierarchy, MILS is hierarchically superior to open surgery and comes second only to liver transplantation.
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Affiliation(s)
- Alessandro Vitale
- Department of Surgical Oncological and Gastroenterological Sciences, Padua University, 35122 Padua, Italy
| | - Roberta Angelico
- Transplant and HPB Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Bruno Sensi
- Transplant and HPB Unit, Department of Surgical Sciences, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Quirino Lai
- General Surgery and Organ Transplantation Unit, AUO Policlinico I of Rome, Sapienza University of Rome, 00185 Rome, Italy
| | - Emanuele Kauffmann
- Division of General and Transplant Surgery, Pisa University, 56126 Pisa, Italy
| | - Irene Scalera
- Unità di Chirurgia Epatobiliare e Trapianti di Fegato, Azienda Ospedaliero-Universitaria Consorziale Policlinico di Bari, 70124 Bari, Italy
| | - Matteo Serenari
- General Surgery and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Sant'Orsola-Malpighi Hospital, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences-DIMEC, Alma Mater Studiorum-University of Bologna, 40126 Bologna, Italy
| | - Michael Ginesini
- Division of General and Transplant Surgery, Pisa University, 56126 Pisa, Italy
| | - Pierluigi Romano
- Department of Surgical Oncological and Gastroenterological Sciences, Padua University, 35122 Padua, Italy
| | - Alessandro Furlanetto
- Department of Surgical Oncological and Gastroenterological Sciences, Padua University, 35122 Padua, Italy
| | - Francesco D'Amico
- Unità di Chirurgia Epatobiliare e Trapianti di Fegato, Azienda Ospedaliero-Universitaria Consorziale Policlinico di Bari, 70124 Bari, Italy
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Lim C, Turco C, Goumard C, Jeune F, Perdigao F, Savier E, Rousseau G, Soubrane O, Scatton O. Perceptions of surgical difficulty in liver transplantation: A European survey and development of the Pitié-Salpêtrière classification. Surgery 2023; 174:979-993. [PMID: 37543467 DOI: 10.1016/j.surg.2023.06.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/01/2023] [Accepted: 06/18/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Significant variations exist regarding the definition of difficult liver transplantation. The study goals were to investigate how liver transplant surgeons evaluate the surgical difficulty of liver transplantation and to use the identified factors to classify liver transplantation difficulty. METHODS A Web-based online European survey was presented to liver transplant surgeons. The survey was divided into 3 parts: (1) participant demographics and practices; (2) various situations based on recipient, liver disease, tumor treatment, and technical factors; and (3) 8 real-life clinical vignettes with different levels of complexity. In part 3 of the survey, respondents were asked whether they would perform liver transplantation but were not aware that these patients eventually underwent liver transplantation. RESULTS A total of 143 invites were sent out, and 97 (67.8%) participants completed the survey. Most participants considered previous spontaneous bacterial peritonitis, previous supra-mesocolic surgery, hypertrophy of segment I, and obesity to be recipient factors for high-difficulty liver transplantation. Most participants considered liver transplantation to be challenging in patients with Budd-Chiari syndrome, Kasai surgery, polycystic liver disease, diffuse portal vein thrombosis, and a history of open hepatectomy. The proportion of participants indicating that liver transplantation was warranted varied across the 8 cases, from 69% to 100%. Our classification of the surgical difficulty of liver transplantation employed these recipient-related, surgical history-related, and liver disease-related variables and 3 difficulty groups were identified: low, intermediate, and high difficulty groups. CONCLUSION This survey provides an overview of the surgical difficulty of various situations in liver transplantation that could be useful for further benchmark and textbook outcome studies.
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Affiliation(s)
- Chetana Lim
- Department of Digestive, Hepato-Biliary, and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France
| | - Célia Turco
- Department of Digestive, Hepato-Biliary, and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France; Centre de Recherche de Saint-Antoine, INSERM, UMRS-938, Paris, France
| | - Claire Goumard
- Department of Digestive, Hepato-Biliary, and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France; Sorbonne Université, Paris, France; Centre de Recherche de Saint-Antoine, INSERM, UMRS-938, Paris, France
| | - Florence Jeune
- Department of Digestive, Hepato-Biliary, and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France
| | - Fabiano Perdigao
- Department of Digestive, Hepato-Biliary, and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France
| | - Eric Savier
- Department of Digestive, Hepato-Biliary, and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France; Centre de Recherche de Saint-Antoine, INSERM, UMRS-938, Paris, France
| | - Géraldine Rousseau
- Department of Digestive, Hepato-Biliary, and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France
| | - Olivier Soubrane
- Department of Digestive Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Olivier Scatton
- Department of Digestive, Hepato-Biliary, and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France; Sorbonne Université, Paris, France; Centre de Recherche de Saint-Antoine, INSERM, UMRS-938, Paris, France.
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Outcomes and Patient Selection in Laparoscopic vs. Open Liver Resection for HCC and Colorectal Cancer Liver Metastasis. Cancers (Basel) 2023; 15:cancers15041179. [PMID: 36831521 PMCID: PMC9954110 DOI: 10.3390/cancers15041179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 02/06/2023] [Accepted: 02/10/2023] [Indexed: 02/15/2023] Open
Abstract
Hepatocellular carcinoma (HCC) and colorectal liver metastasis (CRLM) are the two most common malignant tumors that require liver resection. While liver transplantation is the best treatment for HCC, organ shortages and high costs limit the availability of this option for many patients and make resection the mainstay of treatment. For patients with CRLM, surgical resection with negative margins is the only potentially curative option. Over the last two decades, laparoscopic liver resection (LLR) has been increasingly adopted for the resection of a variety of tumors and was found to have similar long-term outcomes compared to open liver resection (OLR) while offering the benefits of improved short-term outcomes. In this review, we discuss the current literature on the outcomes of LLR vs. OLR for patients with HCC and CRLM. Although the use of LLR for HCC and CRLM is increasing, it is not appropriate for all patients. We describe an approach to selecting patients best-suited for LLR. The four common difficulty-scoring systems for LLR are summarized. Additionally, we review the current evidence behind the emerging robotically assisted liver resection technology.
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Long-Term Results of Endoscopic Metal Stenting for Biliary Anastomotic Stricture after Liver Transplantation. J Clin Med 2023; 12:jcm12041453. [PMID: 36835988 PMCID: PMC9961020 DOI: 10.3390/jcm12041453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/01/2023] [Accepted: 02/09/2023] [Indexed: 02/15/2023] Open
Abstract
(1) Background: Anastomotic biliary stricture (ABS) is a well-known complication of liver transplantation which can lead to secondary biliary cirrhosis and graft dysfunction. The goal of this study was to evaluate the long-term outcomes of endoscopic metal stenting of ABS in the setting of deceased donor liver transplantation (DDLT). (2) Methods: Consecutive DDLT patients with endoscopic metal stenting for ABS between 2010 and 2015 were screened. Data on diagnosis, treatment and follow-up (until June 2022) were collected. The primary outcome was endoscopic treatment failure defined as the need for surgical refection. (3) Results: Among the 465 patients who underwent LT, 41 developed ABS. It was diagnosed after a mean period of 7.4 months (+/-10.6) following LT. Endoscopic treatment was technically successful in 95.1% of cases. The mean duration of endoscopic treatment was 12.8 months (+/-9.1) and 53.7% of patients completed a 1-year treatment. After a mean follow-up of 6.9 years (+/-2.3), endoscopic treatment failed in nine patients (22%) who required surgical refection. Conclusions: Endoscopic management with metal stenting of ABS after DDLT was technically successful in most cases, and half of the patients had at least one year of indwelling stent. Endoscopic treatment long-term failure rate occurred in one fifth of the patients.
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Salvage versus Primary Liver Transplantation for Hepatocellular Carcinoma: A Twenty-Year Experience Meta-Analysis. Cancers (Basel) 2022; 14:cancers14143465. [PMID: 35884526 PMCID: PMC9320001 DOI: 10.3390/cancers14143465] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/04/2022] [Accepted: 07/12/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Primary liver transplantation (PLT) for HCC represents the ideal treatment. However, since organ shortage increases the risk of drop-out from the waiting list for tumor progression, a new surgical strategy has been developed: Salvage Liver Transplantation (SLT) can be offered as an additional curative strategy for HCC recurrence after liver resection. The aim of this updated meta-analysis is to compare surgical and long-term outcomes of SLT versus PLT for HCC. The findings of our analysis reveal that SLT offers comparable surgical outcomes but slightly poorer oncological long-term outcomes with respect to PLT. Abstract (1) Background: Primary liver transplantation (PLT) for HCC represents the ideal treatment. However, since organ shortage increases the risk of drop-out from the waiting list for tumor progression, a new surgical strategy has been developed: Salvage Liver Transplantation (SLT) can be offered as an additional curative strategy for HCC recurrence after liver resection. The aim of this updated meta-analysis is to compare surgical and long-term outcomes of SLT versus PLT for HCC. (2) Materials and Methods: A systematic review and meta-analysis was conducted using the published papers comparing SLT and PLT up to January 2022. (3) Results: 25 studies describing 11,275 patients met the inclusion criteria. The meta-analysis revealed no statistical difference in intraoperative blood loss, overall vascular complications, retransplantation rate, and hospital stay in the SLT group compared with the PLT group. However, the SLT group showed a slightly significant lower 5-year OS rate and 5-year disease-free survival rate. (4) Conclusion: meta-analysis advocates the relative safety and feasibility of both Salvage LT and Primary LT strategies. Specifically, SLT seems to have comparable surgical outcomes but slightly poorer long-term survival than PLT.
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Hendi M, Lv J, Cai XJ. Current status of laparoscopic hepatectomy for the treatment of hepatocellular carcinoma: A systematic literature review. Medicine (Baltimore) 2021; 100:e27826. [PMID: 34918631 PMCID: PMC8677975 DOI: 10.1097/md.0000000000027826] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 10/29/2021] [Indexed: 01/22/2023] Open
Abstract
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.
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Serenari M, Prosperi E, Allard MA, Paterno M, Golse N, Laurenzi A, Adam R, Ravaioli M, Cherqui D, Cescon M. The Impact of Time Interval between Hepatic Resection and Liver Transplantation on Clinical Outcome in Patients with Hepatocellular Carcinoma. Cancers (Basel) 2021; 13:cancers13102398. [PMID: 34063501 PMCID: PMC8156967 DOI: 10.3390/cancers13102398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/11/2021] [Accepted: 05/11/2021] [Indexed: 12/25/2022] Open
Abstract
Simple Summary Recurrence of disease or worsening of liver function after hepatic resection (HR) for hepatocellular carcinoma (HCC) may require secondary liver transplantation (SLT). However, a history of HR is supposed to increase the surgical complexity of LT. This is one of the largest series of SLT and it demonstrates that among all the features analyzed regarding the prior HR, only time interval between HR and SLT was an independent predictor of severe complications after SLT. In particular, an increasing probability of severe complications was observed in those patients who were transplanted close (<15 months) to the HR. There was no significant association between HCC-related death and the time between HR and SLT at the multivariable competing risks regression model. Furthermore, these results remained inside the benchmark values recently reported for LT, confirming that tertiary referral centers with consistent experience in HPB surgery and LT may have benefits in both fields. Abstract Hepatic resection (HR) for hepatocellular carcinoma (HCC) may require secondary liver transplantation (SLT). However, a previous HR is supposed to worsen post-SLT outcomes. Data of patients treated by SLT between 2000 and 2018 at two tertiary referral centers were analyzed. The primary outcome of the study was to analyze the impact of HR on post-LT complications. A Comprehensive Complication Index ≥ 29.6 was chosen as cutoff. The secondary outcome was HCC-related death by means of competing-risk regression analysis. In the study period, 140 patients were included. Patients were transplanted in a median of 23 months after HR (IQR 14–41). Among all the features analyzed regarding the prior HR, only time interval between HR and SLT (time HR-SLT) was an independent predictor of severe complications after LT (OR = 0.98, p < 0.001). According to fractional polynomial regression, the probability of severe complications increased up to 15 months after HR (43%), then slowly decreased over time (OR = 0.88, p < 0.001). There was no significant association between HCC-related death and time HR-SLT at the multivariable competing risks regression model (SHR, 1.06; 95% CI: 0.69–1.62, p = 0.796). This study showed that time HR-SLT was key in predicting complications after LT, without affecting HCC-related death.
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Affiliation(s)
- Matteo Serenari
- General Surgery and Transplant Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Sant’Orsola-Malpighi Hospital, 40138 Bologna, Italy; (M.S.); (A.L.); (M.R.)
| | - Enrico Prosperi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy;
| | - Marc-Antoine Allard
- Centre Hépato-Biliaire, AP-HP Hôpital Paul Brousse, 94805 Villejuif, France; (M.-A.A.); (N.G.); (R.A.); (D.C.)
| | - Michele Paterno
- School of General Surgery, University of Milan, 20157 Milan, Italy;
| | - Nicolas Golse
- Centre Hépato-Biliaire, AP-HP Hôpital Paul Brousse, 94805 Villejuif, France; (M.-A.A.); (N.G.); (R.A.); (D.C.)
| | - Andrea Laurenzi
- General Surgery and Transplant Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Sant’Orsola-Malpighi Hospital, 40138 Bologna, Italy; (M.S.); (A.L.); (M.R.)
| | - René Adam
- Centre Hépato-Biliaire, AP-HP Hôpital Paul Brousse, 94805 Villejuif, France; (M.-A.A.); (N.G.); (R.A.); (D.C.)
| | - Matteo Ravaioli
- General Surgery and Transplant Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Sant’Orsola-Malpighi Hospital, 40138 Bologna, Italy; (M.S.); (A.L.); (M.R.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy;
| | - Daniel Cherqui
- Centre Hépato-Biliaire, AP-HP Hôpital Paul Brousse, 94805 Villejuif, France; (M.-A.A.); (N.G.); (R.A.); (D.C.)
| | - Matteo Cescon
- General Surgery and Transplant Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Sant’Orsola-Malpighi Hospital, 40138 Bologna, Italy; (M.S.); (A.L.); (M.R.)
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy;
- Correspondence:
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Kabir T, Syn NL, Guo Y, Lim KI, Goh BKP. Laparoscopic liver resection for huge (≥10 cm) hepatocellular carcinoma: A coarsened exact-matched single-surgeon study. Surg Oncol 2021; 37:101569. [PMID: 33839442 DOI: 10.1016/j.suronc.2021.101569] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/27/2021] [Accepted: 03/29/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Laparoscopic liver resection (LLR) is increasingly being utilised worldwide for the management of both benign and malignant liver tumours. However, there is limited data to date regarding the safety and feasibility of this approach for huge (≥10 cm) hepatocellular carcinomas (HCCs). We present here our early experience performing LLR for huge HCCs. METHODS We conducted a retrospective review of 280 consecutive patients who underwent LLR by a single surgeon from 2012 to August 2020.15 patients had a preoperative radiological diagnosis of huge (≥10 cm) HCC. Coarsened exact-matched (CEM) weighting was used to compare them to 101 patients who underwent LLR for non-huge HCC. RESULTS After CEM-weighting, both groups were well-balanced for baseline variables. There was no difference in the rates of open conversion. The huge HCC patients had a higher mean Iwate difficulty score than the non-huge HCC patients (9.13 vs 6.53, p = 0.007). As such, the median operating time for the huge HCC group was longer (360 min vs 240min, p = 0.049). However, there were no significant differences in estimated blood loss, proportion of patients requiring blood transfusion, utilization of Pringle maneuver or median Pringle duration. Post-operatively, there were no significant differences in median LOS, overall and major morbidity rates, and 90-day mortality rates between both groups. Median resection margins were also similar for both cohorts. CONCLUSION LLR may be performed successfully for selected patients with huge HCC, with encouraging perioperative outcomes and no compromise in oncologic efficacy.
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Affiliation(s)
- Tousif Kabir
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Department of General Surgery, Sengkang General Hospital, Singapore
| | | | - Yuxin Guo
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Kai-Inn Lim
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Duke NUS Medical School, Singapore.
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Troisi RI, Berardi G, Morise Z, Cipriani F, Ariizumi S, Sposito C, Panetta V, Simonelli I, Kim S, Goh BKP, Kubo S, Tanaka S, Takeda Y, Ettorre GM, Russolillo N, Wilson GC, Cimino M, Montalti R, Giglio MC, Igarashi K, Chan CY, Torzilli G, Cheung TT, Mazzaferro V, Kaneko H, Ferrero A, Geller DA, Han HS, Kanazawa A, Wakabayashi G, Aldrighetti L, Yamamoto M. Laparoscopic and open liver resection for hepatocellular carcinoma with Child-Pugh B cirrhosis: multicentre propensity score-matched study. Br J Surg 2021; 108:196-204. [PMID: 33711132 DOI: 10.1093/bjs/znaa041] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 06/03/2020] [Accepted: 09/18/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Laparoscopic liver resection for hepatocellular carcinoma (HCC) in Child-Pugh A cirrhosis has been demonstrated as beneficial. However, the role of laparoscopy in Child-Pugh B cirrhosis is undetermined. The aim of this retrospective cohort study was to compare open and laparoscopic resection for HCC with Child-Pugh B cirrhosis. METHODS Data on liver resections were gathered from 17 centres. A 1 : 1 propensity score matching was performed according to 17 predefined variables. RESULTS Of 382 available liver resections, 100 laparoscopic and 100 open resections were matched and analysed. The 90-day postoperative mortality rate was similar in open and laparoscopic groups (4.0 versus 2.0 per cent respectively; P = 0.687). Laparoscopy was associated with lower blood loss (median 110 ml versus 400 ml in the open group; P = 0.004), less morbidity (38.0 versus 51.0 per cent respectively; P = 0.041) and fewer major complications (7.0 versus 21.0 per cent; P = 0.010), and ascites was lower on postoperative days 1, 3 and 5. For laparoscopic resections, patients with portal hypertension developed more complications than those without (26 versus 12 per cent respectively; P = 0.002), and patients with a Child-Pugh B9 score had higher morbidity rates than those with B8 and B7 (7 of 8, 10 of 16 and 21 of 76 respectively; P < 0.001). Median hospital stay was 7.5 (range 2-243) days for laparoscopic liver resection and 18 (3-104) days for the open approach (P = 0.058). The 5-year overall survival rate was 47 per cent for open and 65 per cent for laparoscopic resection (P = 0.142). The 5-year disease-free survival rate was 32 and 37 per cent respectively (P = 0.742). CONCLUSION Patients without preoperative portal hypertension and Child-Pugh B7 cirrhosis may benefit most from laparoscopic liver surgery.
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Affiliation(s)
- R I Troisi
- Division of HPB, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy.,Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - G Berardi
- Division of HPB, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy.,Department of Human Structure and Repair, Ghent University, Ghent, Belgium.,Centre for Advanced Treatment of Hepato-Biliary-Pancreatic Diseases, Ageo Central General Hospital, Tokyo, Japan
| | - Z Morise
- Department of Surgery, Fujita Health University Hospital, Toyoake, Japan
| | - F Cipriani
- Hepatobiliary Surgery Division, San Raffaele Hospital, Milan, Italy
| | - S Ariizumi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - C Sposito
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation, Istituto Nazionale Tumori, Milan, Italy
| | - V Panetta
- Biostatistics Department, Sapienza University of Rome, Rome, Italy
| | - I Simonelli
- Biostatistics Department, Sapienza University of Rome, Rome, Italy
| | - S Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul,South Korea
| | - B K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - S Kubo
- Department of Surgery, Osaka City University Hospital, Osaka, Japan
| | - S Tanaka
- Department of Surgery, Osaka City University Hospital, Osaka, Japan
| | - Y Takeda
- Department of Surgery, Kansai Rosai Hospital, Amagasaki, Japan
| | - G M Ettorre
- Department of General and Hepato-Biliary-Pancreatic Surgery, Liver Transplantation Service, San Camillo Forlanini Hospital, Rome, Italy
| | - N Russolillo
- Department of Surgery, Mauriziano Hospital, Turin, Italy
| | - G C Wilson
- Division of Hepatobiliary and Pancreatic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - M Cimino
- Department of General Surgery, Humanitas University and Research Hospital, IRCCS, Milan, Italy
| | - R Montalti
- Department of Public Health, Federico II University, Naples, Italy
| | - M C Giglio
- Division of HPB, Minimally Invasive and Robotic Surgery, Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - K Igarashi
- Centre for Advanced Treatment of Hepato-Biliary-Pancreatic Diseases, Ageo Central General Hospital, Tokyo, Japan
| | - C-Y Chan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - G Torzilli
- Department of General Surgery, Humanitas University and Research Hospital, IRCCS, Milan, Italy
| | - T T Cheung
- Division of Hepato-Biliary-Pancreatic and Liver Transplantation, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - V Mazzaferro
- Department of Hepato-Biliary-Pancreatic Surgery and Liver Transplantation, Istituto Nazionale Tumori, Milan, Italy
| | - H Kaneko
- Department of Surgery, Toho University of Tokyo, Tokyo, Japan
| | - A Ferrero
- Department of Surgery, Mauriziano Hospital, Turin, Italy
| | - D A Geller
- Division of Hepatobiliary and Pancreatic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - H-S Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul,South Korea
| | - A Kanazawa
- Department of Surgery, Osaka City General Hospital, Osaka, Japan
| | - G Wakabayashi
- Centre for Advanced Treatment of Hepato-Biliary-Pancreatic Diseases, Ageo Central General Hospital, Tokyo, Japan
| | - L Aldrighetti
- Hepatobiliary Surgery Division, San Raffaele Hospital, Milan, Italy
| | - M Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
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11
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Gelli M, Sebagh M, Porcher R, Romanelli E, Vibert E, Sa Cunha A, Castaing D, Rosmorduc O, Samuel D, Adam R, Cherqui D. Liver Resection for Early Hepatocellular Carcinoma: Preoperative Predictors of Non Transplantable Recurrence and Implications for Treatment Allocation. Ann Surg 2020; 272:820-826. [PMID: 32833755 DOI: 10.1097/sla.0000000000004259] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIMS LR and LT are the standard curative options for early HCC. LT provides best long-term survival but is limited by organ shortage. LR, readily available, is hampered by high recurrence rates. Salvage liver transplantation is an efficient treatment of recurrences within criteria. The aim of the study was to identify preoperative predictors of non transplantable recurrence (NTR) to improve patient selection for upfront LR or LT at initial diagnosis. STUDY DESIGN Consecutive LR for transplantable HCC between 2000 and 2015 were studied. A prediction model for NTR based on preoperative variables was developed using sub-distribution hazard ratio after multiple imputation and internal validation by bootstrapping. Model performance was evaluated by the concordance index after correction for optimism. RESULTS A total of 148 patients were included. Five-year overall survival and recurrence free survival were 73.6% and 29.3%, respectively (median follow-up 45.8 months). Recurrence rate was 54.8%. NTR rate was 38.2%. Preoperative model for NTR identified >1 nodule [sub-distribution hazard ratio 2.35 95% confidence interval (CI) 1.35-4.09], AFP >100 ng/mL (2.14 95% CI 1.17-3.93), and F4 fibrosis (1.93 95% CI 1.03-3.62). The apparent concordance index of the model was 0.664 after correction for optimism. In the presence of 0, 1, and ≥2 factors, NTR rates were 2.6%, 22.7%, and 40.9%, respectively. The number of prognostic factors was significantly associated with the pattern of recurrence (P = 0.001) and 5-year recurrence free survival (P < 0.001). CONCLUSIONS Cirrhosis, >1 nodule, and AFP >100 ng/mL were identified as preoperative predictors of NTR. In the presence of 2 factors or more upfront transplantation should be probably preferred to resection in regard of organ availability. Other patients are good candidates for LR and salvage liver transplantation should be encouraged in eligible patients with recurrence.
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Affiliation(s)
- Maximiliano Gelli
- Hepatobiliary Center Paul Brousse Hospital, APHP-Université Paris Saclay, Villejuif, France
| | - Mylène Sebagh
- Department of Pathology, APHP - Université Paris Saclay, Hôpital Paul Brousse, Villejuif, France
| | - Raphaël Porcher
- Centre de Recherche Épidémiologie et Statistique (CRESS-UMR1153) Université Paris Descartes-Hôpital Hôtel-Dieu, Paris, France
| | - Elena Romanelli
- Hepatobiliary Center Paul Brousse Hospital, APHP-Université Paris Saclay, Villejuif, France
| | - Eric Vibert
- Hepatobiliary Center Paul Brousse Hospital, APHP-Université Paris Saclay, Villejuif, France
| | - Antonio Sa Cunha
- Hepatobiliary Center Paul Brousse Hospital, APHP-Université Paris Saclay, Villejuif, France
| | - Denis Castaing
- Hepatobiliary Center Paul Brousse Hospital, APHP-Université Paris Saclay, Villejuif, France
| | - Olivier Rosmorduc
- Hepatobiliary Center Paul Brousse Hospital, APHP-Université Paris Saclay, Villejuif, France
| | - Didier Samuel
- Hepatobiliary Center Paul Brousse Hospital, APHP-Université Paris Saclay, Villejuif, France
| | - René Adam
- Hepatobiliary Center Paul Brousse Hospital, APHP-Université Paris Saclay, Villejuif, France
| | - Daniel Cherqui
- Hepatobiliary Center Paul Brousse Hospital, APHP-Université Paris Saclay, Villejuif, France
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12
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Levi Sandri GB, Lai Q, Ravaioli M, Di Sandro S, Balzano E, Pagano D, Magistri P, Di Benedetto F, Rossi M, Gruttadauria S, De Simone P, Ettorre GM, De Carlis L, Cescon M, Colasanti M, Mennini G, Serenari M, Ferla F, Tincani G, Francesco FD, Guidetti C. The Role of Salvage Transplantation in Patients Initially Treated With Open Versus Minimally Invasive Liver Surgery: An Intention-to-Treat Analysis. Liver Transpl 2020; 26:878-887. [PMID: 32246741 DOI: 10.1002/lt.25768] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/02/2020] [Accepted: 03/11/2020] [Indexed: 01/15/2023]
Abstract
Despite gaining wide consensus in the management of hepatocellular carcinoma (HCC), minimally invasive liver surgery (MILS) has been poorly investigated for its role in the setting of salvage liver transplantation (SLT). A multicenter retrospective analysis was carried out in 6 Italian centers on 211 patients with HCC who were initially resected with open (n = 167) versus MILS (n = 44) and eventually wait-listed for SLT. The secondary endpoint was identification of risk factors for posttransplant death and tumor recurrence. The enrolled patients included 211 HCC patients resected with open surgery (n = 167) versus MILS (n = 44) and wait-listed for SLT between January 2007 and December 2017. We analyzed the intention-to-treat survival of these patients. MILS was the most important protective factor for the composite risk of delisting, posttransplant patient death, and HCC recurrence (OR, 0.26; 95% confidence interval [CI], 0.11-0.63; P = 0.003). MILS was also the only independent protective factor for the risk of post-SLT patient death (OR, 0.29; 95% CI, 0.09-0.93; P = 0.04). After propensity score matching, MILS was the only independent protective factor against the risk of delisting, posttransplant death, and HCC recurrence (OR, 0.22; 95% CI, 0.07-0.75; P = 0.02). On the basis of the current analysis, MILS seems protective over open surgery for the risk of delisting, posttransplant patient death, and tumor recurrence. Larger prospective studies balancing liver function and tumor stage are strongly favored to better clarify the beneficial effect of MILS for HCC patients eventually referred to SLT.
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Affiliation(s)
- Giovanni B Levi Sandri
- Division of General Surgery and Liver Transplantation, Polo Ospedaliero Interaziendale Trapianti, San Camillo-Forlanini Hospital, Rome, Italy
| | - Quirino Lai
- Department of General Surgery and Organ Transplantation, Umberto I Hospital, Sapienza University of Rome, Rome, Italy
| | - Matteo Ravaioli
- Department of General Surgery and Transplantation, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Stefano Di Sandro
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Emanuele Balzano
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Duilio Pagano
- Department for the Treatment and the Study of Abdominal Diseases and Abdominal Transplantation, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, University of Pittsburgh Medical Center, Palermo, Italy
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Massimo Rossi
- Department of General Surgery and Organ Transplantation, Umberto I Hospital, Sapienza University of Rome, Rome, Italy
| | - Salvatore Gruttadauria
- Department for the Treatment and the Study of Abdominal Diseases and Abdominal Transplantation, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, University of Pittsburgh Medical Center, Palermo, Italy
| | - Paolo De Simone
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Giuseppe M Ettorre
- Division of General Surgery and Liver Transplantation, Polo Ospedaliero Interaziendale Trapianti, San Camillo-Forlanini Hospital, Rome, Italy
| | - Luciano De Carlis
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Matteo Cescon
- Department of General Surgery and Transplantation, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Marco Colasanti
- Division of General Surgery and Liver Transplantation, Polo Ospedaliero Interaziendale Trapianti, San Camillo-Forlanini Hospital, Rome, Italy
| | - Gianluca Mennini
- Department of General Surgery and Organ Transplantation, Umberto I Hospital, Sapienza University of Rome, Rome, Italy
| | - Matteo Serenari
- Department of General Surgery and Transplantation, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Fabio Ferla
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Giovanni Tincani
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Fabrizio Di Francesco
- Department for the Treatment and the Study of Abdominal Diseases and Abdominal Transplantation, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, University of Pittsburgh Medical Center, Palermo, Italy
| | - Cristiano Guidetti
- Department for the Treatment and the Study of Abdominal Diseases and Abdominal Transplantation, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, University of Pittsburgh Medical Center, Palermo, Italy
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13
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Angelico R, Gazia C. Repeat laparoscopic hepatectomy for recurrent tumors is safe and feasible. An invited commentary on: "Perioperative outcomes comparing laparoscopic with open repeat liver resection for post-hepatectomy recurrent liver cancer: A systematic review and meta-analysis" (Int. J. Surg. 2020; Epub ahead of print). Int J Surg 2020; 78:71-72. [PMID: 32330657 DOI: 10.1016/j.ijsu.2020.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/14/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Roberta Angelico
- Department of Surgical Sciences, HPB and Transplant Unit, University of Rome Tor Vergata, Rome, Italy.
| | - Carlo Gazia
- Department of Surgical Sciences, HPB and Transplant Unit, University of Rome Tor Vergata, Rome, Italy
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14
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Clinical outcome of open surgery versus laparoscopic surgery for cirrhotic hepatocellular carcinoma patients: a meta-analysis. Eur J Gastroenterol Hepatol 2020; 32:239-245. [PMID: 31567715 DOI: 10.1097/meg.0000000000001495] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM Open surgery remains the major approach to treat hepatocellular carcinoma, and laparoscopy-assisted liver resection has been recommended as a superior treatment. However, the efficacy of laparoscopic surgery versus open surgery for cirrhotic patients is under debate. Therefore, the aim of this meta-analysis was to compare the clinical outcomes of laparoscopic and open resection of hepatocellular carcinoma in patients with cirrhosis. METHODS Electronic databases were searched for eligible literature updated on November 2018. After rigorous review of quality, the data were extracted from eligible trials. All the data were pooled with the corresponding 95% confidence interval using RevMan software. Sensitivity analyses and heterogeneity were quantitatively evaluated. RESULTS Fourteen trials met the inclusion criteria. According to the pooled result of surgery duration, laparoscopic surgery was associated with significantly shorter hospital stay [STD mean difference (SMD) = -0.61, 95% confidence interval -0.89 to -0.32; P < 0.0001], lower intraoperative blood loss (SMD = -0.56, 95% confidence interval -0.99 to -0.12; P = 0.01), fewer complications (odds ratio = 0.38, 95% confidence interval 0.28 to 0.52; P < 0.00001) and lower transfusion rate (odds ratio = 0.58, 95% confidence interval 0.36-0.93; P = 0.02). Nevertheless, there was no remarkable difference in operative time (SMD = 0.17, 95% confidence interval -0.25 to -0.59; P = 0.42) between the two groups. The pooled analysis of overall survival showed that laparoscopic surgery did not achieve benefit compared with open surgery (P = 0.02). Moreover, the pooled results of three subgroups indicated that laparoscopic surgery was associated with significantly better disease-free survival (P < 0.05). CONCLUSION The current analysis indicates that laparoscopic liver resection for hepatocellular carcinoma improved intraoperative and disease-free survival, with similar overall survival compared to the open procedure. Laparoscopic surgery may serve as a safe and feasible alternative for selected hepatocellular carcinoma patients with cirrhosis.
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15
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Vega EA, Nicolaescu DC, Salehi O, Kozyreva O, Vellayappan U, Ricklan D, McCarty J, Fontan F, Pomposelli F, Conrad C. Laparoscopic Segment 1 with Partial IVC Resection in Advanced Cirrhosis: How to Do It Safely. Ann Surg Oncol 2019; 27:1143-1144. [PMID: 31848810 DOI: 10.1245/s10434-019-08122-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Laparoscopic versus open hepatocellular carcinoma (HCC) resection reduces morbidity without a compromise in oncologic safety.1-4 Moreover, in the subgroup of cirrhotic patients, a decreased risk of prolonged postoperative ascites and liver decompensation has been reported.5-7 METHODS: A 54-year-old homeless, deaf male with chronic alcoholism, hepatitis C, and advanced cirrhosis was referred with a caudate tumor from a critical access hospital. Imaging showed a 3.6-cm HCC in the caudate lobe compressing the inferior vena cava (IVC). With the patient in reversed, modified French position, the liver was mobilized, and the hepatocaval space dissected. Portal and short hepatic vein branches were individually controlled, and the caudate lobe was dissected off the IVC. At the superior portion of the Spiegel process, the tumor was inseparable from the IVC, necessitating en bloc segment 1 with partial IVC resection. The IVC was reconstructed laparoscopically following a preplanned approach. The pathology report confirmed R0 resection of a moderately differentiated hepatocellular carcinoma without microvascular or perineural invasion (pT1bN0M0). CONCLUSION Laparoscopic caudate lobectomy for cirrhotic patients with partial IVC resection is technically demanding. It therefore requires a strategic and preplanned approach with dedicated instrumentation and laparoscopic skills available. Although the caudal view along the axis of the IVC facilitates dissection, a laparoscopic approach necessitates particular attention to central venous pressure management (intravenous fluid and respiratory tidal volume), meticulous control of portal and short hepatic vein branches, and availability of specialty laparoscopic instrumentation to ensure procedural safety.
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Affiliation(s)
- Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Diana C Nicolaescu
- Medical Doctoral School, Tulcea Emergency Hospital, IOSUD Titu Maiorescu University of Bucharest, Bucharest, Romania
| | - Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Olga Kozyreva
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Usha Vellayappan
- Department of Anesthesia, St. Elizabeth's Medical Center, Boston, MA, USA
| | - David Ricklan
- Department of Pathology, St. Elizabeth's Medical Center, Boston, MA, USA
| | - Justin McCarty
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Fermin Fontan
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Frank Pomposelli
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA. .,General Surgery and Surgical Oncology, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins Street, Suite 201, Boston, MA, 02135, USA.
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16
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Guo Y, Tan EK, Syn NL, Krishnamoorthy TL, Tan CK, Lim R, Lee SY, Chan CY, Cheow PC, Chung AYF, Jeyaraj PR, Goh BKP. Repeat liver resection versus salvage liver transplant for recurrent hepatocellular carcinoma: A propensity score-adjusted and -matched comparison analysis. Ann Hepatobiliary Pancreat Surg 2019; 23:305-312. [PMID: 31824994 PMCID: PMC6893044 DOI: 10.14701/ahbps.2019.23.4.305] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 06/25/2019] [Accepted: 07/04/2019] [Indexed: 12/12/2022] Open
Abstract
Backgrounds/Aims Repeat liver resection (RLR) and salvage liver transplantation (SLT) are viable treatment options for recurrent hepatocellular carcinoma (HCC). With possibly superior survival outcomes than RLR, SLT is however, limited by liver graft availability and poses increased perioperative morbidity. In this study, we seek to compare the outcomes of RLR and SLT for patients with recurrent HCC. Methods Between 1999 and 2018, 94 and 16 consecutive patients who underwent RLR and SLT respectively were identified. Further retrospective subgroup analysis was conducted, comparing 16 RLR with 16 SLT patients via propensity-score matching. Results After propensity-score adjusted analyses, SLT demonstrated inferior short-term perioperative outcomes than RLR, with increased major morbidity (57.8% vs 5.4 %, p=0.0001), reoperations (39.1% vs 0, p<0.0001), renal insufficiency (30.1% vs 3%, p=0.0071), bleeding (19.8% vs 2.2%, p=0.0289), prolonged intensive care unit stay (median=4 vs 0 days, p<0.0001) and hospital stay (median=19.8 vs 7.1days, p<0.001). However, SLT showed significantly lower recurrence rate (15.4% versus 70.3%, p=0.0005) and 5-year cumulative incidence of recurrences (19.4% versus 68.4%, p=0.005). Propensity-matched subgroup analysis showed concordant findings. Conclusions While SLT offers potentially reduced risks of recurrence and trended towards improved long-term survival outcomes relative to RLR, it has poorer short-term perioperative outcomes. Patient selection is prudent amidst organ shortages to maximise allocated resources and optimise patient outcomes.
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Affiliation(s)
- Yuxin Guo
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Ek-Khoon Tan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Nicholas L Syn
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | | | - Chee-Kiat Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Reina Lim
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Ser-Yee Lee
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Chung-Yip Chan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Peng-Chung Cheow
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Alexander Y F Chung
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Prema Raj Jeyaraj
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore.,Duke-National University of Singapore (NUS) Medical School, Singapore
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17
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Wilson GC, Geller DA. Evolving Surgical Options for Hepatocellular Carcinoma. Surg Oncol Clin N Am 2019; 28:645-661. [DOI: 10.1016/j.soc.2019.06.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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18
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Preoperative Prognosticators of Safe Laparoscopic Hepatocellular Carcinoma Resection in Advanced Cirrhosis: a Propensity Score Matching Population-Based Analysis of 1799 Western Patients. J Gastrointest Surg 2019; 23:1157-1165. [PMID: 30820798 DOI: 10.1007/s11605-019-04139-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 01/23/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The safety and oncologic outcomes of patients with advanced cirrhosis undergoing laparoscopic liver resection (LLR) compared to open resection (OLR) for hepatocellular carcinoma (HCC) remain unclear. METHODS Patients with HCC resection during 2010-2014 were identified from the National Cancer Database. Patients with severe fibrosis; single lesions; M0; and known grade, margin status, tumor size, length of hospital stay, 30- and 90-day mortality, 30-day readmission, surgical approach, and complete follow-up were included. A 1:1 propensity score matching analysis of LLR:OLR was performed. Prognostic effect of LLR was assessed by multivariable Cox proportional hazards model. RESULTS A total of 1799 hepatectomy patients (minor (n = 491, 27.3%); major (n = 1308, 72.7%)) were included. Of 193 (10.7%) LLR patients, 190 were eligible for matching. The LLR vs OLR did not differ for patient characteristics, resection margin status, and 30-day (p = 0.141), 90-day mortality (p = 0.121), or 30-day readmission (p = 0.784). Median hospital stay was shorter for LLR (6 vs 8 days, p = 0.001). Median overall survival (OS) was similar for LLR vs OLR (44.2 and 39.5 months, respectively, p = 0.064). Predictors of worse OS were older age (hazard ratio (HR) 1.04, p = 0.034), > 2 comorbidities (HR 1.29, p = 0.012), grade 3-4 disease (HR 1.81, p = 0.025), N1 disease (HR 1.04, p = 0.048), and R1 margins (HR 1.34, p = 0.002). After adjustment for confounders, LLR vs OLR was not a significant risk factor for OS (HR 1.14, 95% CI 0.76-1.71, p = 0.522). CONCLUSION While LLR in advanced cirrhosis for patients with HCC proved safe, optimal patient selection based on the preoperatively available factors comorbidities, age, degree of underlying liver disease, and high-quality oncologic surgery will determine long-term survival.
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19
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Scherber PR, Gäbelein G, Eisele RM, Igna D, Glanemann M. [Early stage liver cancer : Hepatocellular carcinoma]. Chirurg 2019; 89:281-288. [PMID: 29075797 DOI: 10.1007/s00104-017-0538-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Hepatocellular carcinoma (HCC) ranks among the most common primary cancers of the liver. The major risk factor for the formation of HCC is liver cirrhosis. The grade of cirrhosis as well as the extent of the tumor itself, can play an important role in the treatment options and patient prognosis. An operation aimed at an R0 resection is the treatment of choice for patients in an early stage of the disease and is associated with favorable long-term and recurrence-free survival. Liver transplantation offers an even better long-term survival rate after 5 years for selected patients with HCC meeting the Milan criteria as the underlying cirrhosis, the major risk factor for HCC recurrence, is simultaneously treated. Local tumor ablation is the least invasive curative surgical treatment, however, it is associated with an increased local recurrence rate; therefore, the early detection of tumors is of essential importance. As tumor-associated symptoms tend to arise only in advanced tumor stages, it is indispensable to identify patients with typical risk factors and to provide closely monitored screening examinations.
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Affiliation(s)
- P R Scherber
- Klinik für Allgemeine Chirurgie, Viszeral‑, Gefäß- und Kinderchirurgie, Universitätsklinikum des Saarlandes, Kirrbergerstraße 1, 66421, Homburg/Saar, Deutschland
| | - G Gäbelein
- Klinik für Allgemeine Chirurgie, Viszeral‑, Gefäß- und Kinderchirurgie, Universitätsklinikum des Saarlandes, Kirrbergerstraße 1, 66421, Homburg/Saar, Deutschland
| | - R M Eisele
- Klinik für Allgemeine Chirurgie, Viszeral‑, Gefäß- und Kinderchirurgie, Universitätsklinikum des Saarlandes, Kirrbergerstraße 1, 66421, Homburg/Saar, Deutschland
| | - D Igna
- Klinik für Allgemeine Chirurgie, Viszeral‑, Gefäß- und Kinderchirurgie, Universitätsklinikum des Saarlandes, Kirrbergerstraße 1, 66421, Homburg/Saar, Deutschland
| | - M Glanemann
- Klinik für Allgemeine Chirurgie, Viszeral‑, Gefäß- und Kinderchirurgie, Universitätsklinikum des Saarlandes, Kirrbergerstraße 1, 66421, Homburg/Saar, Deutschland.
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21
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Rhu J, Kim JM, Choi GS, Kwon CHD, Joh JW, Soubrane O. Laparoscopy of hepatocellular carcinoma is helpful in minimizing intra-abdominal adhesion during salvage transplantation. Ann Surg Treat Res 2018; 95:258-266. [PMID: 30402444 PMCID: PMC6204328 DOI: 10.4174/astr.2018.95.5.258] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 04/15/2018] [Accepted: 06/01/2018] [Indexed: 01/21/2023] Open
Abstract
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.
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Affiliation(s)
- Jinsoo Rhu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gyu Seong Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Choon Hyuck David Kwon
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Olivier Soubrane
- Hepatobiliary-Pancreatic Surgery, Hospital Beaujon, APHP, Clichy, France
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22
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Kim SH, Kim KH, Ha TY, Jung DH, Park GC, Lee SG. Salvage living donor liver transplantation for recurrent hepatocellular carcinoma after prior laparoscopic hepatectomy. Hepatobiliary Pancreat Dis Int 2018; 17:473-476. [PMID: 30257795 DOI: 10.1016/j.hbpd.2018.09.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Accepted: 09/10/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Seok-Hwan Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea; Department of Surgery, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Ki-Hun Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Tae-Yong Ha
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gil-Chun Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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23
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Long-term survival comparison between primary transplant and upfront curative treatment with salvage transplant for early stage hepatocellular carcinoma. Asian J Surg 2018; 42:433-442. [PMID: 30262437 DOI: 10.1016/j.asjsur.2018.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 08/14/2018] [Accepted: 08/17/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Whether primary liver transplantation (PLT) or upfront curative treatment with salvage liver transplantation (SLT) is a better treatment option for early hepatocellular carcinoma (HCC) is controversial. This study aims to compare the long-term survival starting from the time of primary treatment between the two approaches for early HCC using propensity score matching (PSM) analysis. METHODS From 1995 to 2014, 175 patients with early HCC undergoing either PLT (n = 149) or SLT (n = 26) were retrospectively reviewed in a prospectively collected database. Patients' demographic data, tumor characteristics, short-term and long-term outcome were compared between two groups after PSM. RESULTS After matching, the baseline characteristics were comparable between mPLT group (n = 45) and mSLT group (n = 25). The tumor recurrence rate after transplant was significantly higher in mSLT group than mPLT group (28% vs. 15.6%). Calculating from the time of primary treatment, the 1, 3, and 5-year overall survival rates were comparable between mPLT group (97.8%, 91.1% and 86.3%) and mSLT group (100%, 95% and 85%). However, the 1, 3, and 5-year recurrence-free survival rates were significantly better in mPLT group than mSLT group (95.6% vs. 90%, 86.6% vs. 80% and 84.3% vs. 70%). SLT approach and high pre-treatment serum alpha-fetoprotein level (>200 ηg/mL) were poor prognostic factors for recurrence-free survival after transplant. CONCLUSIONS PLT may be a better treatment option for early HCC, whereas SLT approach for HCC should be cautiously considered under the circumstance of organ shortage.
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24
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Di Sandro S, Danieli M, Ferla F, Lauterio A, De Carlis R, Benuzzi L, Buscemi V, Pezzoli I, De Carlis L. The current role of laparoscopic resection for HCC: a systematic review of past ten years. Transl Gastroenterol Hepatol 2018; 3:68. [PMID: 30363804 DOI: 10.21037/tgh.2018.08.05] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 08/22/2018] [Indexed: 12/12/2022] Open
Abstract
The use of laparoscopic liver resection (LLR) has progressively spread in the last 10 years. Several studies have shown the superiority of LLR to open liver resection (OLR) in term of perioperative outcomes. With this review, we aim to systematically assess short-term and long-term major outcomes in patients who underwent LLR for hepatocellular carcinoma (HCC) in order to illustrate the advantages of minimally invasive liver surgery. Through an advanced PubMed research, we selected all retrospective, prospective, and comparative clinical trials reporting short-term and long-term outcomes of any series of patients with diagnosis of HCC who underwent laparoscopic or robotic resection. Reviews, meta-analyses, or case reports were excluded. None of the patients included in this review has received a previous locoregional treatment for the same tumor nor has undergone a laparoscopic-assisted procedure. We considered morbidity and mortality for evaluation of major short-term outcomes, and overall survival (OS) and disease-free survival (DFS) for evaluation of long-term outcomes. A total of 1,501 patients from 17 retrospective studies were included, 15 studies compare LLR with OLR. Propensity-score matching (PSM) analysis was used in 11 studies (975 patients). The majority of the studies included patients with good liver function and a single HCC. Cirrhosis at pathology ranged from 33% to 100%. Overall mortality and morbidity ranges were 0-2.4% and 4.9-44% respectively, with most of the complications being Clavien-Dindo grade I or II (range: 3.9-23.3% vs. 0-9.52% for Clavien I-II and ≥ III respectively). The median blood loss ranged from 150 to 389 mL; the range of the median duration of surgery was 134-343 minutes. The maximum rate of conversion was 18.2%. The median duration of hospitalization ranged from 4 to 13 days. The ranges of overall survival rates at 1-, 3- and 5-year were 72.8-100%, 60.7-93.5% and 38-89.7% respectively. The ranges of disease free survival rates at 1-, 3- and 5-year were 45.5-91.5%, 20-72.2% and 19-67.8% respectively. The benefits of LLR in term of complication rate, blood loss, and duration of hospital stay make this procedure an advantageous alternative to OLR, especially for cirrhotic patients in whom the use of LLR reduces the risk of post-hepatectomy liver failure. The limits of LLR can be overcome by robotic surgery, which could therefore be preferred. Further benefits of minimally invasive surgery derive from its ability to reduce the formation of adhesions in view of a salvage liver transplant. In conclusion, the results of this review seem to confirm the safety and feasibility of LLR for HCC as well as its superiority to OLR according to perioperative outcomes.
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Affiliation(s)
- Stefano Di Sandro
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy.,Niguarda Transplant Foundation, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Maria Danieli
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Fabio Ferla
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Andrea Lauterio
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Riccardo De Carlis
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Laura Benuzzi
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Vincenzo Buscemi
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Isabella Pezzoli
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy
| | - Luciano De Carlis
- Department of General Surgery and Transplantation, Niguarda Ca' Granda Hospital, Milan, Italy.,School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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25
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Guerra F, Di Marino M, Coratti A. Robotic Surgery of the Liver and Biliary Tract. J Laparoendosc Adv Surg Tech A 2018; 29:141-146. [PMID: 30118390 DOI: 10.1089/lap.2017.0628] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The laparoscopic methods for major abdominal surgery are gaining increasing acceptance worldwide. Despite its relatively recent introduction in clinical practice, robotics has been accepted as an effective option to perform high-demanding procedures such as those required in hepatobiliary surgery. Some potential advantages over conventional laparoscopy have been suggested, but its actual role in clinical practice is still to be defined. METHODS The objective of this work is to critically review the available evidence on the application of robotic surgery to the liver and biliary tract. PubMed, Embase, and the Cochrane Library electronic databases were systematically searched for studies reporting on robotic hepatobiliary surgery with or without comparison with open surgery or conventional laparoscopy. RESULTS This review provides a comprehensive snapshot of the current application of the robot to the surgery of the liver and biliary tract. The overall available data show the noninferiority of the robotic system to conventional open and laparoscopic surgery. A number of studies suggest some potential advantages in performing high-demanding procedures in a minimally invasive fashion. CONCLUSIONS The robot can be used to perform various types of liver surgeries quite safely and competently, although the lack of randomized control trials, comparing it with open and laparoscopic surgery, precludes the possibility to reach definitive conclusions.
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Affiliation(s)
- Francesco Guerra
- Division of Oncological and Robotic General Surgery, Careggi University Hospital , Florence, Italy
| | - Michele Di Marino
- Division of Oncological and Robotic General Surgery, Careggi University Hospital , Florence, Italy
| | - Andrea Coratti
- Division of Oncological and Robotic General Surgery, Careggi University Hospital , Florence, Italy
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26
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Yadav DK, Chen W, Bai X, Singh A, Li G, Ma T, Yu X, Xiao Z, Huang B, Liang T. Salvage Liver Transplant versus Primary Liver Transplant for Patients with Hepatocellular Carcinoma. Ann Transplant 2018; 23:524-545. [PMID: 30072683 PMCID: PMC6248033 DOI: 10.12659/aot.908623] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background The strategy of salvage liver transplantation (SLT) originated for initially resectable and transplantable hepatocellular carcinoma (HCC) to preclude upfront transplantation, with SLT in the case of recurrence. However, SLT remains a controversial approach in comparison to primary liver transplant (PLT). The aim of our study was to conduct a systemic review and meta-analysis to assess the short-term outcomes, overall survival (OS), and disease-free survival (DFS) between SLT and PLT for patients with HCC, stratifying results according to the Milan criteria and donor types. Material/Methods A search of PubMed, EMBASE, and the Cochrane Library was conducted to identify studies comparing SLT and PLT. A fixed effects model and a random effects model meta-analysis were conducted to assess the short-term outcomes, OS, and DFS based on the evaluation of heterogeneity. Results SLT had superior 1-year, 3-year, and 5-year OS and DFS compared with that of PLT. After classifying data according to donor type and Milan criteria, our meta-analysis revealed: that for deceased-donor liver transplantation (DDLT) recipients, there were no significant differences in 1-year and 3-year OS rate between the SLT group and the PLT group. However, the 5-year OS rate was superior in the SLT group compared to the PLT group. Similarly, SLT had superior 1-year, 3-year, and 5-year OS rate compared to PLT in living-donor liver transplantation (LDLT) recipients. Moreover, 1-year, 3-year, and 5-year DFS were also superior in SLT compared to PLT in both the DDLT and LDLT recipients. In patients within Milan criteria there were no statistically significant differences in 1-year, 3-year, and 5-year OS and DFS between the SLT group and the PLT group. Similarly, in patients beyond Milan criteria, both SLT and PLT showed no significant difference for 1-year, 3-year, and 5-year OS rate. Conclusions Our meta-analysis included the largest number of studies comparing SLT and PLT, and SLT was found to have significantly better OS and DFS. Moreover, this meta-analysis suggests that SLT has comparable postoperative complications to that of PLT, and thus, SLT may be a better treatment strategy for recurrent HCC patients and patients with compensated liver, whenever feasible, considering the severe organ limitation and the safety of SLT. However, PLT can be referred as a treatment strategy for HCC patients with cirrhotic and decompensated liver.
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Affiliation(s)
- Dipesh Kumar Yadav
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China (mainland)
| | - Wei Chen
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China (mainland)
| | - Xueli Bai
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China (mainland)
| | - Alina Singh
- Department of Surgery, Bir Hospital, National Academy of Medical Science (NAMS), Kanti Path, Kathmandu, Nepal
| | - Guogang Li
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China (mainland)
| | - Tao Ma
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China (mainland)
| | - Xiazhen Yu
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China (mainland)
| | - Zhi Xiao
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China (mainland)
| | - Bingfeng Huang
- Department of Hepatobiliary and Pancreatic Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China (mainland)
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27
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Morise Z. Laparoscopic liver resection for the patients with hepatocellular carcinoma and chronic liver disease. Transl Gastroenterol Hepatol 2018; 3:41. [PMID: 30148226 DOI: 10.21037/tgh.2018.07.01] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 06/29/2018] [Indexed: 12/12/2022] Open
Abstract
Liver resection (LR), liver transplantation (LT), transarterial chemoembolization, and local ablation therapy are the treatment options for hepatocellular carcinoma (HCC). Although LR, LT and local ablation therapy (only for small tumor) provide the best hope for cure, most patients with HCC have also chronic liver disease (CLD) backgrounds, including HCV-liver cirrhosis. Therefore, they are at high risk for development of postoperative complications-sometimes fatal-and metachronous multicentric recurrent tumors occurring from the preneoplastic CLD background. Appropriate treatment is selected for HCC patients, on the combined evaluations of tumor condition and liver function. However, not small number of patients cannot undergo any treatment option due to poor liver function and/or complicated tumor condition. After repeated treatments, it can happen more often. It is thought that the features of laparoscopic LR could lead to the expansion of the LR indication to those patients, in the settings of severe CLD, repeat LR and bridging to LT. In our experience, Child-Pugh (CP) score is one of the promising candidates as a selection indicator which correlates well to our indication criteria of surface small laparoscopic LR to severe CLD patients, patient's performance status, and prognosis. Portal hypertension should be also counted in the selection criteria.
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Affiliation(s)
- Zenichi Morise
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
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28
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Mashchenko I, Trtchounian A, Buchholz C, de la Torre AN. A Sling Technique for Laparoscopic Resection of Segment Seven of the Liver. JSLS 2018; 22:JSLS.2018.00017. [PMID: 29977110 PMCID: PMC6020890 DOI: 10.4293/jsls.2018.00017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Introduction: As the incidence of liver cancer continues to increase in the setting of cirrhosis, parenchyma-sparing liver resection is increasingly necessary. A technique is described that involves using a sling made from 1-inch-wide packing gauze to retract and rotate the liver to divide the right triangular and coronary ligaments and mobilize segment 7. The right lobe is rotated anteriorly and counterclockwise, allowing access and parenchymal transection of segment 7 under ultrasonographic guidance. Case Presentation: Seven patients with tumors in segment 7 underwent resection with the technique described above: 4 had Child's A cirrhosis and hepatocellular carcinoma (HCC), 1 had metastatic colon cancer, 1 had an adenoma, and 1 had a symptomatic hemangioma. Tumor size ranged between 2.5 and 7.7 cm. Blood loss during resection was between 150 and 500 mL. No patients required transfusion as a result of surgery. With the exception of 1 patient with Clostridium difficile colitis, the average hospital stay was 3.8 days. Management and Outcome: Parenchyma-sparing laparoscopic resection of segment 7 is feasible and can be safely performed using a sling for intracorporal hepatic retraction, manipulation, and positioning. Given the risk of HCC recurrence, laparoscopic liver resection may also be better suited for subsequent salvage liver transplant because of less perihepatic adhesions.
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Affiliation(s)
- Igor Mashchenko
- Department of Surgery, St Georges University School of Medicine, Grenada, West Indies
| | - Anna Trtchounian
- Department of Surgery, St Georges University School of Medicine, Grenada, West Indies
| | - Christopher Buchholz
- Department of Bariatric Surgery, Hackensack Medical Center, Hackensack, New Jersey
| | - Andrew N de la Torre
- Department of Surgery, New Jersey Medical School, Rutger's University, Newark, New Jersey
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29
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Viganò L, Laurenzi A, Solbiati L, Procopio F, Cherqui D, Torzilli G. Open Liver Resection, Laparoscopic Liver Resection, and Percutaneous Thermal Ablation for Patients with Solitary Small Hepatocellular Carcinoma (≤30 mm): Review of the Literature and Proposal for a Therapeutic Strategy. Dig Surg 2018; 35:359-371. [PMID: 29890512 DOI: 10.1159/000489836] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 05/05/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patients with a single hepatocellular carcinoma (HCC) ≤3 cm and preserved liver function have the highest likelihood to be cured if treated. The most adequate treatment methods are yet a matter that is debated. METHODS We reviewed the literature about open anatomic resection (AR), laparoscopic liver resection (LLR), and percutaneous thermal ablation (PTA). RESULTS PTA is effective as resection for HCC < 2 cm, when they are neither subcapsular nor perivascular. PTA in HCC of 2-3 cm is under evaluation. AR with the removal of the tumor-bearing portal territory is recommended for HCC > 2 cm, except for subcapsular ones. In comparison with open surgery, LRR has better short-term outcomes and non-inferior long-term outcomes. LLR is standardized for superficial limited resections and for left-sided AR. CONCLUSIONS According to the available evidences, the following therapeutic proposal can be advanced. Laparoscopic limited resection is the standard for any subcapsular HCC. PTA is the first-line treatment for deep-located HCC < 2 cm, except for those in contact with Glissonean pedicles. Laparoscopic AR is the standard for deep-located HCC of 2-3 cm of the left liver, while open AR is the standard for deep-located HCC of 2-3 cm in the right liver. HCC in contact with Glissonean pedicles should be scheduled for resection (open or laparoscopic) independent of their size. Liver transplantation is reserved to otherwise untreatable patients or as a salvage procedure at recurrence.
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Affiliation(s)
- Luca Viganò
- Department of Surgery, Division of Hepatobiliary and General Surgery, Humanitas Research Hospital, IRCCS, Rozzano, Milano, Italy.,Department of Biomedical Sciences, Humanitas University, Rozzano, Milano, Italy
| | - Andrea Laurenzi
- Department of Surgery, Centre Hépatobiliaire, Paul Brousse Hospital, Villejuif, France
| | - Luigi Solbiati
- Department of Radiology, Humanitas Research Hospital, IRCCS, Rozzano, Milano, Italy.,Department of Biomedical Sciences, Humanitas University, Rozzano, Milano, Italy
| | - Fabio Procopio
- Department of Surgery, Division of Hepatobiliary and General Surgery, Humanitas Research Hospital, IRCCS, Rozzano, Milano, Italy
| | - Daniel Cherqui
- Department of Surgery, Centre Hépatobiliaire, Paul Brousse Hospital, Villejuif, France
| | - Guido Torzilli
- Department of Surgery, Division of Hepatobiliary and General Surgery, Humanitas Research Hospital, IRCCS, Rozzano, Milano, Italy.,Department of Biomedical Sciences, Humanitas University, Rozzano, Milano, Italy
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30
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Kang WH, Kim KH, Jung DH, Park GC, Kim SH, Cho HD, Lee SG. Long-term results of laparoscopic liver resection for the primary treatment of hepatocellular carcinoma: role of the surgeon in anatomical resection. Surg Endosc 2018; 32:4481-4490. [PMID: 29691651 DOI: 10.1007/s00464-018-6194-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 04/20/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Liver resection is a potentially curative therapy for hepatocellular carcinoma (HCC). LLR is a newly developed and safe technique associated with shorter hospital stay, less pain, better cosmetic outcomes, and similar complication rates as open surgery; however, data on its long-term outcomes remain scarce. METHODS We retrospectively examined the clinical and follow-up data of 234 patients who underwent LLR (performed by a single surgeon in all cases) for the primary treatment of HCC between July 2007 and December 2015 at Asan Medical Center. RESULTS The mean patient age was 55.63 (range 31-76) years; 167 were men. The median follow-up duration was 38 (range 6-116) months. A total of 227 patients (97.0%) had Child-Turcotte-Pugh grade A disease. Of them, 167 (71.4%) underwent anatomical resections and 63 (28.6%) underwent non-anatomical partial hepatectomies. Overall survival rates were 98.3, 91.7, and 87.1%, and recurrence-free survival rates were 82.1, 67.5, and 55.3% at 1, 3, and 5 years, respectively. In Cox regression analysis, anatomical resection was a risk factor for recurrence (univariate analysis: hazard ratio [HR] 0.49; 95% confidence interval [CI] 0.31-0.75; p = 0.001; multivariate analysis: HR 0.59; 95% CI 0.38-0.94; p = 0.025). CONCLUSIONS LLR is an acceptable primary treatment for patients with HCC with good hepatic function and with an appropriate anatomical structure, and is associated with improved prognosis. LLR can achieve lower recurrence rates through anatomical resection.
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Affiliation(s)
- Woo-Hyoung Kang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Ki-Hun Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
| | - Dong-Hwan Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Gil-Chun Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Seok-Hwan Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Hwui-Dong Cho
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
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31
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Le Roux F, Rebibo L, Cosse C, Chatelain D, Nguyen-Khac E, Badaoui R, Regimbeau JM. Benefits of Laparoscopic Approach for Resection of Liver Tumors in Cirrhotic Patients. J Laparoendosc Adv Surg Tech A 2018; 28:553-561. [PMID: 29350570 DOI: 10.1089/lap.2017.0584] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Liver resection in cirrhotic patients is associated with increased morbidity and mortality. The objective of this study was to compare short-term results of laparoscopic resection (LR) and open surgery (OS) for minor liver resection in patients with hepatocellular carcinoma (HCC) hepatocellularcarcinoma on nontumor cirrhotic liver (HCC/F4) and patients with colorectal cancer liver metastases (CRLMs) colorectal liver metastases on healthy liver (CRLM/F0). MATERIALS AND METHODS Between January 2005 and December 2014, all patients undergoing liver resection (n = 754) were included in this study. Liver resections for cholangiocarcinoma or benign tumor, major liver resection (≥3 segments), HCC on healthy liver, CRLM on cirrhotic liver, and liver resection with technically difficult accessibility (segments I, VII, and VIII) were excluded. The primary endpoint of the study was a validated composite endpoint (CEP), which included specific liver surgery complications (Clavien ≥III), allowing comparison of the postoperative course after LR versus OR for HCC/F4 patients and CRLM/F0 patients using propensity score (PS) analysis. Secondary endpoints were major postoperative morbidity according to the Clavien-Dindo classification (≥III) and intensive care unit (ICU) length of hospital stay (LOS) and overall LOS. The test group was defined as HCC/F4 patients operated by LR, and the control group was defined as HCC/F4 patients and CRLM/F0 patients operated by OS and CRLM/F0 patient operated by LR. RESULTS Sixty patients (38.7%) underwent LR and 95 patients (61.3%) underwent OS. Surgery was performed for CRLM in 93 patients (60%) and for HCC in 62 patients (40%). No difference was demonstrated between HCC/F4 patients and CRLM/F0 patients in the LR group in terms of the CEP (7% versus 18.1%; P = .23), while a significant difference for the CEP was observed between HCC/F4 patients and CRLM/F0 patients after OS (50% versus 21%; P = .021). A higher rate of CEP was observed for HCC/F4 patients operated by OS compared to HCC/F4 patients operated by LR (50% versus 7.8%; P = .009). No significant difference in Clavien-Dindo score ≥III was observed between HCC/F4 patients and CRLM/F0 patients operated by LR (10% versus 4.5%; P = .98). A higher postoperative ascites rate was observed for HCC/F4 patients operated by OS compared to CRLM/F0 patients operated by OS (25% versus 2.8%; P = .006). This difference was no longer observed when HCC/F4 patients were compared to CRLM/F0 operated by LR (7.8% versus 2.8%; P = .09). The postoperative mortality rate was 1.8% and was not correlated with nontumor liver or surgical approach. A shorter LOS was observed for HCC/F4 patients operated by LR compared to HCC/F4 patients operated by OS (7.53 versus 17.13; P = .011). CONCLUSION The laparoscopic approach for malignant liver tumor is associated with a lower specific complication rate. LR for HCC/F4 could eliminate excess morbidity and decrease LOS in patients with cirrhotic liver.
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Affiliation(s)
- Fabien Le Roux
- 1 Department of Digestive Surgery, South Hospital, Amiens University Hospital , Amiens, France
| | - Lionel Rebibo
- 1 Department of Digestive Surgery, South Hospital, Amiens University Hospital , Amiens, France
| | - Cyril Cosse
- 1 Department of Digestive Surgery, South Hospital, Amiens University Hospital , Amiens, France .,2 Medical Research Department, Research and Methodology Unit, Amiens University Hospital , Amiens, France
| | - Denis Chatelain
- 3 Department of Pathology, Amiens University Hospital , Amiens, France
| | - Eric Nguyen-Khac
- 4 Department of Hepatogastroenterology, Amiens University Hospital , Amiens, France
| | - Rachid Badaoui
- 5 Department of Anesthesiology, Amiens University Hospital , Amiens, France
| | - Jean-Marc Regimbeau
- 1 Department of Digestive Surgery, South Hospital, Amiens University Hospital , Amiens, France .,6 Medical Research Department, EA4294, Jules Verne University of Picardie , Amiens, France
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Ziogas IA, Tsoulfas G. Advances and challenges in laparoscopic surgery in the management of hepatocellular carcinoma. World J Gastrointest Surg 2017; 9:233-245. [PMID: 29359029 PMCID: PMC5752958 DOI: 10.4240/wjgs.v9.i12.233] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/04/2017] [Accepted: 12/05/2017] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma is the fifth most common malignancy and the third most common cause of cancer-related mortality worldwide. From the wide variety of treatment options, surgical resection and liver transplantation are the only therapeutic ones. However, due to shortage of liver grafts, surgical resection is the most common therapeutic modality implemented. Owing to rapid technological development, minimally invasive approaches have been incorporated in liver surgery. Liver laparoscopic resection has been evaluated in comparison to the open technique and has been shown to be superior because of the reported decrease in surgical incision length and trauma, blood loss, operating theatre time, postsurgical pain and complications, R0 resection, length of stay, time to recovery and oral intake. It has been reported that laparoscopic excision is a safe and feasible approach with near zero mortality and oncologic outcomes similar to open resection. Nevertheless, current indications include solid tumors in the periphery < 5 cm, especially in segments II through VI, while according to the consensus laparoscopic major hepatectomy should only be performed by surgeons with high expertise in laparoscopic and hepatobiliary surgery in tertiary centers. It is necessary for a surgeon to surpass the 60-cases learning curve observed in order to accomplish the desirable outcomes and preserve patient safety. In this review, our aim is to thoroughly describe the general principles and current status of laparoscopic liver resection for hepatocellular carcinoma, as well as future prospects.
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Affiliation(s)
- Ioannis A Ziogas
- Medical School, Aristotle University of Thessaloniki, Thessaloniki 54453, Greece
| | - Georgios Tsoulfas
- Associate Professor of Surgery, 1st Department of Surgery, Aristotle University of Thessaloniki, Thessaloniki 54453, Greece
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Lim C, Shinkawa H, Hasegawa K, Bhangui P, Salloum C, Gomez Gavara C, Lahat E, Omichi K, Arita J, Sakamoto Y, Compagnon P, Feray C, Kokudo N, Azoulay D. Salvage liver transplantation or repeat hepatectomy for recurrent hepatocellular carcinoma: An intent-to-treat analysis. Liver Transpl 2017; 23:1553-1563. [PMID: 28945955 DOI: 10.1002/lt.24952] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 08/09/2017] [Accepted: 09/17/2017] [Indexed: 02/07/2023]
Abstract
The salvage liver transplantation (LT) strategy was conceived for initially resectable and transplantable hepatocellular carcinoma (HCC) to obviate upfront transplantation, with salvage LT in the case of recurrence. The longterm outcomes of a second resection for recurrent HCC have improved. The aim of this study was to perform an intention-to-treat analysis of overall survival (OS) comparing these 2 strategies for initially resectable and transplantable recurrent HCC. From 1994 to 2011, 391 patients with HCC who underwent salvage LT (n = 77) or a second resection (n = 314) were analyzed. Of 77 patients in the salvage LT group, 21 presented with resectable and transplantable recurrent HCC and 18 underwent transplantation. Of 314 patients in the second resection group, 81 presented with resectable and transplantable recurrent HCC and 81 underwent a second resection. The 5-year intention-to-treat OS rates, calculated from the time of primary hepatectomy, were comparable between the 2 strategies (72% for salvage transplantation versus 77% for second resection; P = 0.57). In patients who completed the salvage LT or second resection procedure, the 5-year OS rates, calculated from the time of the second surgery, were comparable between the 2 strategies (71% versus 71%; P = 0.99). The 5-year disease-free survival (DFS) rates were 72% following transplantation and 18% following the second resection (P < 0.001). Similar results were observed after propensity score matching. In conclusion, although the 5-year OS rates were similar in the salvage LT and second resection groups, the salvage LT strategy still achieves better DFS. Second resection for recurrent HCC might be considered to be the best alternative option to LT in the current organ shortage. Liver Transplantation 23 1553-1563 2017 AASLD.
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Affiliation(s)
- Chetana Lim
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation and, Henri Mondor Hospital, AP-HP, Paris-Est University, Créteil, France
| | - Hiroji Shinkawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Prashant Bhangui
- Medanta Institute of Liver Transplantation and Regenerative Medicine, New Delhi, India
| | - Chady Salloum
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation and, Henri Mondor Hospital, AP-HP, Paris-Est University, Créteil, France
| | - Concepcion Gomez Gavara
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation and, Henri Mondor Hospital, AP-HP, Paris-Est University, Créteil, France
| | - Eylon Lahat
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation and, Henri Mondor Hospital, AP-HP, Paris-Est University, Créteil, France
| | - Kiyohiko Omichi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Junichi Arita
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yoshihiro Sakamoto
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Philippe Compagnon
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation and, Henri Mondor Hospital, AP-HP, Paris-Est University, Créteil, France
| | - Cyrille Feray
- Department of Hepatology, Henri Mondor Hospital, AP-HP, Paris-Est University, Créteil, France
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Daniel Azoulay
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation and, Henri Mondor Hospital, AP-HP, Paris-Est University, Créteil, France
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Minimally invasive surgery as a treatment option for gastric cancer with liver metastasis: a comparison with open surgery. Surg Endosc 2017; 32:1422-1433. [PMID: 29075971 DOI: 10.1007/s00464-017-5826-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 08/11/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND As minimally invasive techniques advances, minimally invasive surgery (MIS) has emerged as an alternative modality for advanced gastric cancer. In this study, we compared the short- and long-term surgical outcomes of MIS and conventional open surgery for gastric cancer liver metastasis (GCLM) in terms of safety, feasibility, and efficacy. METHODS This retrospective study used data from a prospective database at the Chinese People's Liberation Army General Hospital. From January 2006 to June 2016, 53 gastric cancer patients with synchronous liver metastasis accepted radical gastrectomy combined with either or both hepatectomy and radiofrequency ablation for liver metastases. The 53 patients enrolled in the study were divided into two groups: a conventional open surgery group (n = 42) and an MIS group (n = 11). Propensity score matching (PSM) analysis was performed to overcome possible bias. RESULTS With PSM performed at a 1:3 ratio, 11 patients who received MIS were compared with 33 open surgery cases. Mean operation time was significantly longer for the MIS group compared with the open surgery group (301 vs. 236 min, P = 0.032), while the open surgery group had a larger estimated blood loss than the MIS group (421 vs. 196 ml, P = 0.019). Time to first flatus and postoperative complications, including Clavien-Dindo classification, were similar in the two groups. However, patients undergoing MIS had a significantly shorter time to first sips of water (P = 0.020) and soft diet (P = 0.020) compared with open surgery counterparts. Long-term outcomes were comparable between groups (P = 0.090) after adjustment by PSM analysis. CONCLUSIONS MIS achieved superior short-term outcomes and comparable long-term outcomes compared with open surgery in GCLM patients. For experienced surgeons, both laparoscopic and robotic methods of MIS are reasonable approaches for the management of highly selected GCLM patients.
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Laparoscopic Management of Hepatocellular Carcinoma: A Critical Reappraisal. Surg Laparosc Endosc Percutan Tech 2017; 27:203-205. [DOI: 10.1097/sle.0000000000000415] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Salvage Versus Primary Liver Transplantation for Early Hepatocellular Carcinoma: Do Both Strategies Yield Similar Outcomes? Ann Surg 2017; 264:155-63. [PMID: 26649581 DOI: 10.1097/sla.0000000000001442] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND DATA In compensated cirrhotics with early hepatocellular carcinoma (HCC-cirr), upfront liver resection (LR) and salvage liver transplantation (SLT) in case of recurrence may have outcomes comparable to primary LT (PLT). OBJECTIVE An intention-to-treat (ITT) analysis comparing PLT and SLT strategies. METHODS Of 130 HCC-cirr patients who underwent upfront LR (group LR), 90 (69%) recurred, 31 could undergo SLT (group SLT). During the same period, 366 patients were listed for LT (group LLT); 26 dropped-out (7.1%), 340 finally underwent PLT (group PLT). We compared survival between groups LR and LLT, LR and PLT, and PLT and SLT. RESULTS Feasibility of SLT strategy was 34% (31/90). In an ITT analysis, group LLT had better 5-yr/10-yr overall survival (OS) compared with group LR (68%/58% vs. 58%/35%; P = 0.008). Similarly, 5-yr/10-yr OS and disease-free survival (DFS) were better in group PLT versus group LR (OS 73%/63% vs. 58%/35%, P = 0.0007; DFS 69%/61% vs. 27%/21%, P < 0.0001). Upfront resection and microvascular tumor invasion were poor prognostic factors for both OS and DFS, presence of satellite tumor nodules additionally predicted worse DFS. Group SLT had similar postoperative and long-term outcomes compared with group PLT (starting from time of LT) (OS 54%/54% vs. 73%/63%, P = 0.35; DFS 48%/48% vs. 69%/61%, P = 0.18, respectively). CONCLUSIONS In initially transplantable HCC-cirr patients, ITT survival was better in group PLT compared with group LR. SLT was feasible in only a third of patients who recurred after LR. Post SLT, short and long-term outcomes were comparable with PLT. Better patient selection for the "resection first" approach and early detection of recurrence may improve outcomes of the SLT strategy.
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Pure Laparoscopic Versus Open Right Hepatectomy for Hepatocellular Carcinoma in Patients With Cirrhosis: A Propensity Score Matched Analysis. Ann Surg 2017; 265:856-863. [PMID: 27849661 DOI: 10.1097/sla.0000000000002072] [Citation(s) in RCA: 151] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We aimed to describe our experience with pure laparoscopic right hepatectomy (LRH) and to compare its outcomes with those of open right hepatectomy (ORH) in hepatocellular carcinoma (HCC) patients with liver cirrhosis. BACKGROUND Laparoscopic liver resection has been reported as a safe and effective approach for the management of liver cancer; however, its outcomes have not been evaluated in a large cohort of HCC patients with liver cirrhosis. METHODS We retrospectively reviewed the medical records of 152 patients who underwent pure LRH (n = 37) or ORH (n = 115) between June 2008 and July 2015 at the Asan Medical Center in Seoul, Korea. We performed 1:1 propensity score matching between the LRH and ORH groups. Subsequently, 33 patients were included in each group. RESULTS There was no statistically significant difference between the LRH and ORH groups regarding the rate of complications (P = 0.053). However, the mean comprehensive complication index, which accounts for the severity of complications, was significantly lower in the LRH group (0.63 vs 4.42; P = 0.025). There were no significant differences between the LRH and ORH groups regarding 2-year disease-free survival rate or 2-year overall survival rate (P = 0.645 and P = 0.090, respectively). CONCLUSIONS Even in patients with cirrhosis, pure LRH is not less safe than the traditional open approach. The oncological outcomes of HCC were also comparable between the two groups. In selected patients, pure LRH for HCC appears to represent a viable alternative to ORH.
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Xiong Q, Geng TT, He L, Gao H. Harm and Benefits of Salvage Transplantation for Hepatocellular Carcinoma: An Updated Meta-analysis. Transplant Proc 2017; 48:3336-3347. [PMID: 27931579 DOI: 10.1016/j.transproceed.2016.09.047] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 09/01/2016] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The aim of this work was to compare salvage liver transplantation (SLT) and primary liver transplantation (PLT) in terms of the harm and benefits. METHODS The authors searched Pubmed, Embase, and the Cochrane Library from their dates of establishment to December 2015. Based on selection and exclusion criteria, 2 researchers screened the literature independently. The meta-analysis was performed with the use of the Review Manager software. Meta-analysis of the pooled standard mean difference (SMD) and odds ratio (OR) with 95% confidence interval (CI) were calculated based on either a fixed-effects or a random-effects model. In addition, risk of bias was assessed with the use of the Newcastle-Ottawa scale. RESULTS Sixteen studies were selected, involving almost 8,707 patients. According to the pooled estimates, compared with PLT, SLT was associated with a longer operative time (SMD, 0.28; 95% CI, 0.11-0.46;), higher intraoperative blood loss (SMD, 0.41; 95% CI, 0.08-0.75;), more postoperative bleeding (OR, 1.95; 95% CI, 1.10-3.45), an increased risk of recurrence (OR, 2.08; 95% CI, 1.24-3.50), and poorer 3-year (OR, 0.86; 95% CI, 0.76-0.98) and 5-year (OR, 0.86; 95% CI, 0.76-0.98) overall survival rates. However, no difference was detected between case and control groups in either rates of postoperative complications or such aspects as perioperative mortality, length of intensive care unit stay, length of hospital stay, and 1-year overall survival rate. CONCLUSIONS The 3-year and 5-year overall survival rates were inferior in SLT, which shows that PLT is a better treatment strategy for transplantable hepatocellular carcinoma (HCC). However, considering the severe organ limitation and the feasibility and safety of SLT, it provides a better option for patients with HCC recurrence after curative resection.
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Affiliation(s)
- Q Xiong
- Department of Hepatobiliary Surgery, People's Hospital of Deyang City, Deyang, Sichuan, People's Republic of China
| | - T-T Geng
- School of Public Health, University of Queensland, Brisbane, Queensland, Australia
| | - L He
- Department of Nursing, People's Hospital of Deyang City, Deyang, Sichuan, People's Republic of China.
| | - H Gao
- Center for Lipid Research, Key Laboratory of Molecular Biology on Infectious Diseases, Ministry of Education, Chongqing Medical University, Chongqing, People's Republic of China
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Sotiropoulos GC, Prodromidou A, Kostakis ID, Machairas N. Meta-analysis of laparoscopic vs open liver resection for hepatocellular carcinoma. Updates Surg 2017; 69:291-311. [PMID: 28220382 DOI: 10.1007/s13304-017-0421-4] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 02/06/2017] [Indexed: 02/07/2023]
Abstract
Laparoscopic liver resections (LLR) are widely accepted as safe and effective procedures for the management of hepatocellular carcinoma (HCC) in the hands of experienced surgeons. The efficacy and extent of benefits of pure as well as hand-assisted laparoscopic and laparoscopy-assisted liver resection over open liver resection (OLR) have been investigated by numerous studies during the last 10 years. The aim of our meta-analysis is to investigate the effect of LLR in short- and long-term outcomes compared to OLR in patients operated for HCC. A total of 5203 patients from forty-four studies were included in our meta-analysis reporting for short- and long-term results for both LLR and OLR for HCC. Among them, 1830 underwent pure laparoscopic hepatectomy, 282 underwent pure laparoscopic or hand-assisted laparoscopic or laparoscopy-assisted hepatectomy, and 3091 were operated through open approach. LLRs were found to be significantly associated with lower blood loss, need for blood transfusion, successful achievement of R0 resection as well as wider resection margin, shorter hospital stay, lower morbidity and 30-day mortality rates. Operative time, tumor recurrence, 1-, 3-, and 5-year overall survival as well as 1-, 3-, and 5-year disease-free survival were not found different between the groups. This meta-analysis clearly demonstrates the superiority of laparoscopic resection over the open approach for patients with small HCC.
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Affiliation(s)
- Georgios C Sotiropoulos
- 2nd Department of Propaedeutic Surgery, National and Kapodistrian University of Athens, Medical School, General Hospital Laiko, Agiou Thoma Str. 17, 11527, Athens, Greece
| | - Anastasia Prodromidou
- 2nd Department of Propaedeutic Surgery, National and Kapodistrian University of Athens, Medical School, General Hospital Laiko, Agiou Thoma Str. 17, 11527, Athens, Greece
| | - Ioannis D Kostakis
- 2nd Department of Propaedeutic Surgery, National and Kapodistrian University of Athens, Medical School, General Hospital Laiko, Agiou Thoma Str. 17, 11527, Athens, Greece
| | - Nikolaos Machairas
- 2nd Department of Propaedeutic Surgery, National and Kapodistrian University of Athens, Medical School, General Hospital Laiko, Agiou Thoma Str. 17, 11527, Athens, Greece.
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Goutte N, Bendersky N, Barbier L, Falissard B, Farges O. Laparoscopic left lateral sectionectomy: a population-based study. HPB (Oxford) 2017; 19:118-125. [PMID: 27956026 DOI: 10.1016/j.hpb.2016.11.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 11/02/2016] [Accepted: 11/05/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoscopic left lateral sectionectomy (LLS) has now become standard practice. However, published series are small and retrospective. The aim was to compare at a national level the use and short-term outcome of laparoscopic and open LLS. METHODS National hospital discharge databases were screened to identify all adult patients who had undergone elective LLS in France between 2007 and 2012. Outcome measurements included blood transfusion, severe morbidity, mortality and length of hospital stay. The independent influence of the laparoscopic approach on these outcomes was tested overall and after stratifying for the indication (benign condition, primary malignancy, liver metastasis). RESULTS Over the 6-year study period, 2198 patients underwent LLS, accounting for 6.9% of all elective liver resections. Some 28.5% of LLS procedures were performed laparoscopically. Among hospitals in which LLS was carried out, 33.2% of procedures were done laparoscopically (median 2 laparoscopic LLS resections per year). The laparoscopic approach was independently associated with a shorter length of hospital stay irrespective of the indication, and a lower transfusion rate in patients with benign condition or primary malignancy. CONCLUSION LLS is seldom performed and the laparoscopic approach has not been adopted widely. The potential benefit of laparoscopic LLS varies according to the indication.
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Affiliation(s)
- Nathalie Goutte
- Pôle des Maladies Digestives U773 - Université Paris Nord Val de Seine, Hôpital Beaujon, Assistance Publique - Hôpitaux de Paris, Clichy, France
| | - Noelle Bendersky
- Department of Medical Informatics, Hôpital Beaujon, Clichy, France
| | - Louise Barbier
- Department of HPB and Pancreatic Surgery, Hôpital Beaujon, Clichy, Assistance Publique Hôpitaux de Paris, Université Paris Nord Val de Seine, France
| | - Bruno Falissard
- U669 - Université Paris Sud, Hôpital Cochin - Maison des adolescents, Paris, France
| | - Olivier Farges
- Department of HPB and Pancreatic Surgery, Hôpital Beaujon, Clichy, Assistance Publique Hôpitaux de Paris, Université Paris Nord Val de Seine, France.
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Levi Sandri GB, de Werra E, Mascianà G, Colasanti M, Santoro R, D'Andrea V, Ettorre GM. Laparoscopic and robotic approach for hepatocellular carcinoma-state of the art. Hepatobiliary Surg Nutr 2016; 5:478-484. [PMID: 28124002 DOI: 10.21037/hbsn.2016.05.05] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Hepatocellular carcinoma (HCC) is the sixth most common malignant tumor worldwide and the most common primary liver cancer, in over 80% of cases HCC grown on a cirrhotic liver. Laparoscopic liver resection (LLR) is now worldwide accepted considering the excellent results shown. Minimally invasive surgical approach for HCC is increasing continuously and in specialized centers seems to become the first-line approach for those patients. The aim of this review presents and discusses state of the art in the laparoscopic and robotic surgical treatment of HCC. An electronic search was performed to identify all studies dealing with HCC resected with laparoscopy or robotic approach. Indications for laparoscopic resection, robotic assisted and totally robotic resection of HCC will be doubtless increased in future years. LLR and robotic approach for HCC is safe and feasible.
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Affiliation(s)
- Giovanni Battista Levi Sandri
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy;; Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Edoardo de Werra
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy
| | - Gianluca Mascianà
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy
| | - Marco Colasanti
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy
| | - Roberto Santoro
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy
| | - Vito D'Andrea
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Maria Ettorre
- Division of General Surgery and Liver Transplantation, S. Camillo Hospital, Rome, Lazio, Italy
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Levi Sandri GB, de Werra E, Mascianà G, Guerra F, Spoletini G, Lai Q. The use of robotic surgery in abdominal organ transplantation: A literature review. Clin Transplant 2016; 31. [PMID: 27726195 DOI: 10.1111/ctr.12856] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2016] [Indexed: 12/13/2022]
Affiliation(s)
- Giovanni B. Levi Sandri
- Division of General Surgery and Liver Transplantation; San Camillo Hospital; Rome Italy
- Department of Surgical Sciences; Sapienza University of Rome; Rome Italy
| | - Edoardo de Werra
- Division of General Surgery and Liver Transplantation; San Camillo Hospital; Rome Italy
| | - Gianluca Mascianà
- Division of General Surgery and Liver Transplantation; San Camillo Hospital; Rome Italy
| | - Francesco Guerra
- Division of Oncological and Robotic General Surgery; Careggi University Hospital; Florence Italy
| | - Gabriele Spoletini
- Department of HPB and Liver Transplant Surgery; Royal Free Hospital; London UK
| | - Quirino Lai
- Transplant Unit; Department of Surgery; University of L'Aquila; San Salvatore Hospital; L'Aquila Italy
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Kawaguchi Y, Honda G, Endo I, Cherqui D, Kokudo N. Current Technical Issues for Surgery of Primary Liver Cancer. Liver Cancer 2016; 6:51-58. [PMID: 27995088 PMCID: PMC5159717 DOI: 10.1159/000449345] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Primary liver cancer is the fifth most common cancer worldwide. Apart from liver transplantation, surgical resection has been accepted as the effective local treatment for hepatocellular carcinoma (HCC), one of the most common primary liver cancers. Recent technological innovations including navigation technology and intraoperative real-time fluorescence guidance have been utilized for liver resections in clinical practice. With respect to liver resection techniques, the laparoscopic approach has been increasingly gaining popularity as one of the minimally-invasive treatments of HCC. These technological innovations and technical advancements are expected to further improve the safety and efficacy of liver resections.
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Affiliation(s)
- Yoshikuni Kawaguchi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Goro Honda
- Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Daniel Cherqui
- Hepatobiliary Center, Paul Brousse Hospital, Université Paris Sud, Paris, France
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan,*Norihiro Kokudo, MD, PhD Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655 (Japan), Tel. +81 3 5800 8841, E-Mail
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Cherqui D, Wakabayashi G, Geller DA, Buell JF, Han HS, Soubrane O, O'Rourke N. The need for organization of laparoscopic liver resection. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:665-667. [PMID: 27770492 DOI: 10.1002/jhbp.401] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 09/13/2016] [Indexed: 12/23/2022]
Abstract
In this article, we present the rationale for creating a new society aiming at organizing laparoscopic liver surgery. It has been named International Laparoscopic Liver Society (ILLS). Its main mission is to facilitate the diffusion and education of laparoscopic liver resection for meaningful improvements in patient care. This will include organization of a biannual congress dedicated to laparoscopic liver resection, coordination of international registries, helping in the education of surgeons wishing to learn these techniques including travel grants, provide a website serving as a forum supporting collaboration between surgeons interested in the advancement of laparoscopic liver resection techniques (http://www.ills.global/). ILLS aims at working in collaboration with existing HPB societies.
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Affiliation(s)
- Daniel Cherqui
- Hepatobiliary Center, Paul Brousse Hospital - University Paris Sud, 14 Avenue Paul Vaillant Couturier, 94800, Villejuif, France
| | - Go Wakabayashi
- Department of Surgery, Ageo Central General Hospital, Ageo, Saitama, Japan
| | - David A Geller
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Joseph F Buell
- Department of Surgery, Tulane University, New Orleans, Louisiana, USA
| | - Ho-Seong Han
- Department of Surgery, Seoul National University, College of Medicine, Seoul National Universtiy Bundang Hospital, Seongnam, South Korea
| | - Olivier Soubrane
- Department of HPB Surgery and Liver Transplant, Beaujon Hospital - University Denis Diderot, Paris, France
| | - Nicholas O'Rourke
- Department of Surgery, Royal Brisbane Hospital, Brisbane, Queensland, Australia
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HERMAN P, LOPES FDLM, KRUGER JAP, FONSECA GM, JEISMANN VB, COELHO FF. IS RESECTION OF HEPATOCELLULAR CARCINOMA IN THE ERA OF LIVER TRANSPLANTATION WORTHWILE? A single center experience. ARQUIVOS DE GASTROENTEROLOGIA 2016; 53:169-74. [DOI: 10.1590/s0004-28032016000300009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 03/08/2016] [Indexed: 02/07/2023]
Abstract
ABSTRACT Background - Liver resection for hepatocellular carcinoma is a potentially curative therapeutic procedure that can be performed readily after its indication, without the need of a long waiting time and lower costs when compared to liver transplantation, being a good alternative in patients with preserved/good liver function. Objective - Evaluate long-term results of liver resection from a high volume single center for selected patients with hepatocellular carcinoma in a context of a long waiting list for liver transplant. Methods - One hundred and one patients with hepatocellular carcinoma, with a mean age of 63.1 years, and preserved liver function were submitted to liver resection. Clinical and pathological data were evaluated as prognostic factors. Mean follow-up was 39.3 months. Results - All patients had a single nodule and 57 (58.2%) patients were within the Milan criteria. The size of the nodule ranged from 1 to 24 cm in diameter. In 74 patients, liver resection was performed with the open approach and in 27 (26.7%) was done laparoscopically. Postoperative morbidity was 55.3% being 75.5% of the complications classified as Dindo-Clavien I and II and operative mortality was 6.9%. Five-year overall and disease free survival rates were 49.9% and 40.7%, respectively.After a log-rank univariate analysis, the levels of preoperative alpha-fetoprotein (P=0.043), CA19-9 (P=0.028), capsule invasion (P=0.03), positive margin (R1-R2) (P=0.004) and Dindo-Claviens' morbidity classification IV (P=0.001) were the only parameters that had a significant negative impact on overall survival. On the odds-ratio evaluation, the only significant factors for survival were high levels of alpha-fetoprotein (P=0.037), and absence of free margins (P=0.008). Conclusion - Resection, for selected cases, is a potentially curative treatment with acceptable morbidity and mortality and, in a context of a long waiting list for transplant, plays an important role for the treatment of hepatocellular carcinoma.
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Krüger JAP, Fonseca GM, Coelho FF, Jeismann V, Herman P. Laparoscopic Right Hepatectomy for Cirrhotic Patients: Takasaki's Hilar Control and Caudal Approach. Ann Surg Oncol 2016; 24:558-559. [PMID: 27271928 DOI: 10.1245/s10434-016-5288-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cirrhotic patients bearing hepatocellular carcinomas (HCC) derive benefits from laparoscopic hepatectomy1 - 6 such as reduced bleeding, less overall and liver-specific complications, and fewer adhesions in the case of future reoperation or transplantation.7 - 10 Bleeding is concerning in the setting of cirrhosis,11 - 15 and adequate inflow control reduces blood loss. The caudal approach is the laparoscopic counterpart of the anterior approach to open surgery. It implies in parenchymal transection initiated from the visceral surface of the liver after limited hepatic mobilization, reducing the risk of increased circulating tumoral cells.16 - 18 Venous outflow transection and completion of ligament mobilization are left as last steps. METHODS A 46 years-old-male with hepatitis C virus and alcoholic cirrhosis was diagnosed with a 4-cm HCC (right hepatic lobe). Expected future liver remnant was 45 % of his total liver volume. A totally laparoscopic right hepatectomy was performed using six ports, and the specimen was removed through a Pfannenstiel auxiliary incision. A 10-mm 30° scope was used. The pneumoperitoneum pressure was set to 12 mmHg. The right hepatic pedicle, the caudate lobe, and the major hepatic veins were managed with laparoscopic vascular staplers. RESULTS Surgery was performed with limited liver mobilization and en bloc extrafascial right pedicle control (Takasaki's technique),19 followed by caudal parenchymal transection along the paracaval plane. The operative time was 450 min, and the estimated blood loss was 800 ml (no transfusion was required). CONCLUSION The laparoscopic Takasaki technique and caudal approach are feasible procedures in the setting of cirrhosis, resulting in an oncologic adequate intervention with less morbidity.
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Affiliation(s)
- Jaime Arthur Pirola Krüger
- Hospital das Clinicas (HC/FMUSP), University of Sao Paulo, São Paulo, Brazil. .,Instituto do Cancer do Estado de Sao Paulo (ICESP), University of Sao Paulo, São Paulo, Brazil.
| | | | | | - Vagner Jeismann
- Hospital das Clinicas (HC/FMUSP), University of Sao Paulo, São Paulo, Brazil.,Instituto do Cancer do Estado de Sao Paulo (ICESP), University of Sao Paulo, São Paulo, Brazil
| | - Paulo Herman
- Hospital das Clinicas (HC/FMUSP), University of Sao Paulo, São Paulo, Brazil
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Sposito C, Battiston C, Facciorusso A, Mazzola M, Muscarà C, Scotti M, Romito R, Mariani L, Mazzaferro V. Propensity score analysis of outcomes following laparoscopic or open liver resection for hepatocellular carcinoma. Br J Surg 2016; 103:871-80. [PMID: 27029597 DOI: 10.1002/bjs.10137] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 01/12/2016] [Accepted: 01/29/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Liver resection is a potentially curative approach for hepatocellular carcinoma (HCC). Laparoscopic liver resections may reduce complication rates, especially in patients with cirrhosis. The aim of this study was to compare the results of laparoscopic liver resection with those of open liver resection for HCC. METHODS Patients with cirrhosis who underwent minor liver resections for HCC from 2006 to 2013 were identified retrospectively from a prospective database according to the technique adopted (laparoscopic or open). Short- and long-term outcomes were compared between the two groups before and after 1 : 1 propensity score matching. RESULTS A total of 269 patients were considered: 226 who underwent open liver resection and 43 who had a laparoscopic procedure. The two groups differed at baseline in terms of median age, sex, performance status, tumour location and type of resection. After propensity score matching, two comparable groups of 43 patients each were obtained. Intraoperative bleeding, margin clearance and operative mortality were similar in the two groups, whereas complication rates were lower (49 versus 19 per cent in open versus laparoscopic groups respectively; P = 0·004) and median hospital stay was shorter (8 versus 5 days; P < 0·001) in the laparoscopic group. On multivariable logistic regression analysis, the only independent factor that reduced the risk of postoperative complications was the use of laparoscopy (odds ratio 0·12, 95 per cent c.i. 0·03 to 0·55; P = 0·006). Median overall survival was 57·8 months in the open group and 48·8 months in the laparoscopic group (P = 0·802). Median disease-free survival was 31·7 and 25·5 months respectively (P = 0·990). CONCLUSION In comparison with the open approach, laparoscopic minor liver resections for HCC improved short-term outcomes, with similar survival results.
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Affiliation(s)
- C Sposito
- Gastrointestinal Surgery and Liver Transplantation, Unit of Clinical Epidemiology, Fondazione IRCCS Istituto Nazionale Tumori (National Cancer Institute), Milan, Italy
| | - C Battiston
- Gastrointestinal Surgery and Liver Transplantation, Unit of Clinical Epidemiology, Fondazione IRCCS Istituto Nazionale Tumori (National Cancer Institute), Milan, Italy
| | - A Facciorusso
- Gastrointestinal Surgery and Liver Transplantation, Unit of Clinical Epidemiology, Fondazione IRCCS Istituto Nazionale Tumori (National Cancer Institute), Milan, Italy
| | - M Mazzola
- Gastrointestinal Surgery and Liver Transplantation, Unit of Clinical Epidemiology, Fondazione IRCCS Istituto Nazionale Tumori (National Cancer Institute), Milan, Italy
| | - C Muscarà
- Gastrointestinal Surgery and Liver Transplantation, Unit of Clinical Epidemiology, Fondazione IRCCS Istituto Nazionale Tumori (National Cancer Institute), Milan, Italy
| | - M Scotti
- Gastrointestinal Surgery and Liver Transplantation, Unit of Clinical Epidemiology, Fondazione IRCCS Istituto Nazionale Tumori (National Cancer Institute), Milan, Italy
| | - R Romito
- Gastrointestinal Surgery and Liver Transplantation, Unit of Clinical Epidemiology, Fondazione IRCCS Istituto Nazionale Tumori (National Cancer Institute), Milan, Italy
| | - L Mariani
- Trial Office, Fondazione IRCCS Istituto Nazionale Tumori (National Cancer Institute), Milan, Italy
| | - V Mazzaferro
- Gastrointestinal Surgery and Liver Transplantation, Unit of Clinical Epidemiology, Fondazione IRCCS Istituto Nazionale Tumori (National Cancer Institute), Milan, Italy
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Coelho FF, Kruger JAP, Fonseca GM, Araújo RLC, Jeismann VB, Perini MV, Lupinacci RM, Cecconello I, Herman P. Laparoscopic liver resection: Experience based guidelines. World J Gastrointest Surg 2016; 8:5-26. [PMID: 26843910 PMCID: PMC4724587 DOI: 10.4240/wjgs.v8.i1.5] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 09/07/2015] [Accepted: 11/25/2015] [Indexed: 02/06/2023] Open
Abstract
Laparoscopic liver resection (LLR) has been progressively developed along the past two decades. Despite initial skepticism, improved operative results made laparoscopic approach incorporated to surgical practice and operations increased in frequency and complexity. Evidence supporting LLR comes from case-series, comparative studies and meta-analysis. Despite lack of level 1 evidence, the body of literature is stronger and existing data confirms the safety, feasibility and benefits of laparoscopic approach when compared to open resection. Indications for LLR do not differ from those for open surgery. They include benign and malignant (both primary and metastatic) tumors and living donor liver harvesting. Currently, resection of lesions located on anterolateral segments and left lateral sectionectomy are performed systematically by laparoscopy in hepatobiliary specialized centers. Resection of lesions located on posterosuperior segments (1, 4a, 7, 8) and major liver resections were shown to be feasible but remain technically demanding procedures, which should be reserved to experienced surgeons. Hand-assisted and laparoscopy-assisted procedures appeared to increase the indications of minimally invasive liver surgery and are useful strategies applied to difficult and major resections. LLR proved to be safe for malignant lesions and offers some short-term advantages over open resection. Oncological results including resection margin status and long-term survival were not inferior to open resection. At present, surgical community expects high quality studies to base the already perceived better outcomes achieved by laparoscopy in major centers’ practice. Continuous surgical training, as well as new technologies should augment the application of laparoscopic liver surgery. Future applicability of new technologies such as robot assistance and image-guided surgery is still under investigation.
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Cai X, Liang X, Yu T, Liang Y, Jing R, Jiang W, Li J, Ying H. Liver cirrhosis grading Child-Pugh class B: a Goliath to challenge in laparoscopic liver resection?-prior experience and matched comparisons. Hepatobiliary Surg Nutr 2016; 4:391-7. [PMID: 26734623 DOI: 10.3978/j.issn.2304-3881.2015.09.02] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Laparoscopic hepatectomy (LH) is highly difficult in the background of liver cirrhosis. In this case series, we aimed to summarize our prior experience of LH in liver cirrhosis grading Child-Pugh class B. METHODS In the LH database of Sir Run Run Shaw Hospital in Zhejiang, China, patients who were pathologically diagnosed with cirrhosis and graded as Child-Pugh class B or C were reviewed. RESULTS Five patients grading Child B were included. There was no Child C case in our LH database. For included cases, median blood loss (BL) was 800 (range, 240-1,000) mL, median operative time was 135 (range, 80-170) minutes, and median length of hospital stay was 9 (range, 7-15) days. Forty percent (2/5) of patients was converted to open. The postoperative complication (PC) rate was 20.0% (1/5). When these Child B cases were compared with Child A cases undergoing LH, there was no statistical significance in BL, complication rate, operative time, open rate and hospital stay (HS) (P>0.05). This finding was confirmed by two ways of matched comparisons (a 1:2 comparison based on age and gender, and a 1:1 propensity score matching). CONCLUSIONS Although relevant literatures had suggested feasibility of LH in cirrhotic cases grading Child A, this study was the first one to discuss the value of LH in Child B cases. Our prior experience showed that in selected patients, LH in Child B patients had the potential to be as safe as in Child A cases. The efficacy of LH in Child C patients needs further exploration.
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Affiliation(s)
- Xiujun Cai
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Institute of Minimally Invasive Surgery, Zhejiang University, Hangzhou 310016, China
| | - Xiao Liang
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Institute of Minimally Invasive Surgery, Zhejiang University, Hangzhou 310016, China
| | - Tunan Yu
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Institute of Minimally Invasive Surgery, Zhejiang University, Hangzhou 310016, China
| | - Yuelong Liang
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Institute of Minimally Invasive Surgery, Zhejiang University, Hangzhou 310016, China
| | - Renan Jing
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Institute of Minimally Invasive Surgery, Zhejiang University, Hangzhou 310016, China
| | - Wenbing Jiang
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Institute of Minimally Invasive Surgery, Zhejiang University, Hangzhou 310016, China
| | - Jianbo Li
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Institute of Minimally Invasive Surgery, Zhejiang University, Hangzhou 310016, China
| | - Hanning Ying
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Institute of Minimally Invasive Surgery, Zhejiang University, Hangzhou 310016, China
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Teo JY, Kam JH, Chan CY, Goh BKP, Wong JS, Lee VTW, Cheow PC, Chow PKH, Ooi LLPJ, Chung AYF, Lee SY. Laparoscopic liver resection for posterosuperior and anterolateral lesions-a comparison experience in an Asian centre. Hepatobiliary Surg Nutr 2016; 4:379-90. [PMID: 26734622 DOI: 10.3978/j.issn.2304-3881.2015.06.06] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Minimally invasive surgery has been one of the recent developments in liver surgery, laparoscopic liver resection (LLR) was initially performed for benign lesions at easily accessible locations. As the surgical techniques, technology and experience improved over the past decades, LLR surgery had evolved to tackle malignant lesions, major resections and even in difficult locations without compromising safety and principles of oncology. It was also shown to be beneficial in cirrhotic patients. We describe our initial experience with LLR in a population with significant proportion having cirrhosis, emphasising our approach for lesions in the posterosuperior (PS) segments of the liver (segments 1, 4a, 7, and 8). METHODS A review of patients undergoing LLR in single institution from 2006 to 2015 was performed from a prospective surgical database. Clinicopathological, operative and perioperative parameters were analyzed to compare outcomes in patients who underwent LLR for PS vs. anterolateral lesions (AL). RESULTS LLR was performed in consecutive 197 patients, with a mean age of 60 years. The indications for resection were hepatocellular carcinoma (HCC) (n=105; 53%), colorectal cancer liver metastasis (n=31; 16%), other malignancies (n=19; 10%) and benign lesions (n=42; 21%). A significant proportion had liver cirrhosis (25.9%). More females underwent surgery in the AL group and indications for surgery were similar between both groups. Major liver resection was performed more frequently for the PS group than for the AL group (P<0.001) and significantly more PS resections was performed in our latter experience (P=0.02). The mean operative time and the conversion rate were significantly greater in the PS group than in the AL group (P≤0.001 and 0.03, respectively). However, the estimated blood loss (EBL), rate of blood transfusion and mean postoperative stay were similar in the two groups (P=0.04, 0.88 and 0.92, respectively). The overall 90-day morbidity and mortality rate was 21.3% and 0.5% respectively, with no differences between the two groups. Surrogates of difficulty such as operative time, blood loss, conversion and outcomes e.g., morbidity and mortality, were similar in patients who underwent PS resections with or without cirrhosis. CONCLUSIONS LLR in selected patients is technically feasible and safe including cirrhotic patients with lesions in the PS segments.
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Affiliation(s)
- Jin Yao Teo
- 1 Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore ; 2 Duke-NUS Graduate Medical School, Singapore ; 3 Division of Surgical Oncology, National Cancer Center Singapore, Singapore ; 4 Office of Clinical Sciences, Duke-NUS Graduate Medical School, Singapore
| | - Juinn Huar Kam
- 1 Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore ; 2 Duke-NUS Graduate Medical School, Singapore ; 3 Division of Surgical Oncology, National Cancer Center Singapore, Singapore ; 4 Office of Clinical Sciences, Duke-NUS Graduate Medical School, Singapore
| | - Chung Yip Chan
- 1 Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore ; 2 Duke-NUS Graduate Medical School, Singapore ; 3 Division of Surgical Oncology, National Cancer Center Singapore, Singapore ; 4 Office of Clinical Sciences, Duke-NUS Graduate Medical School, Singapore
| | - Brian K P Goh
- 1 Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore ; 2 Duke-NUS Graduate Medical School, Singapore ; 3 Division of Surgical Oncology, National Cancer Center Singapore, Singapore ; 4 Office of Clinical Sciences, Duke-NUS Graduate Medical School, Singapore
| | - Jen-San Wong
- 1 Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore ; 2 Duke-NUS Graduate Medical School, Singapore ; 3 Division of Surgical Oncology, National Cancer Center Singapore, Singapore ; 4 Office of Clinical Sciences, Duke-NUS Graduate Medical School, Singapore
| | - Victor T W Lee
- 1 Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore ; 2 Duke-NUS Graduate Medical School, Singapore ; 3 Division of Surgical Oncology, National Cancer Center Singapore, Singapore ; 4 Office of Clinical Sciences, Duke-NUS Graduate Medical School, Singapore
| | - Peng Chung Cheow
- 1 Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore ; 2 Duke-NUS Graduate Medical School, Singapore ; 3 Division of Surgical Oncology, National Cancer Center Singapore, Singapore ; 4 Office of Clinical Sciences, Duke-NUS Graduate Medical School, Singapore
| | - Pierce K H Chow
- 1 Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore ; 2 Duke-NUS Graduate Medical School, Singapore ; 3 Division of Surgical Oncology, National Cancer Center Singapore, Singapore ; 4 Office of Clinical Sciences, Duke-NUS Graduate Medical School, Singapore
| | - London L P J Ooi
- 1 Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore ; 2 Duke-NUS Graduate Medical School, Singapore ; 3 Division of Surgical Oncology, National Cancer Center Singapore, Singapore ; 4 Office of Clinical Sciences, Duke-NUS Graduate Medical School, Singapore
| | - Alexander Y F Chung
- 1 Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore ; 2 Duke-NUS Graduate Medical School, Singapore ; 3 Division of Surgical Oncology, National Cancer Center Singapore, Singapore ; 4 Office of Clinical Sciences, Duke-NUS Graduate Medical School, Singapore
| | - Ser Yee Lee
- 1 Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore ; 2 Duke-NUS Graduate Medical School, Singapore ; 3 Division of Surgical Oncology, National Cancer Center Singapore, Singapore ; 4 Office of Clinical Sciences, Duke-NUS Graduate Medical School, Singapore
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