Laparoscopic liver resections in normal and cirrhotic livers: a retrospective analysis in a tertiary hepato-biliary unit

Laparoscopic versus open resection of hepatocellular carcinoma in patients with cirrhosis

Hepatocellular carcinoma (HCC) is the sixth commonest malignancy worldwide, and the fourth-leading cause of cancer related death. Partial liver resection (LR) forms the mainstay of therapy for suitable patients with preserved liver function. In recent years, significant advances in surgical technology, refinement of operative techniques and improvements in peri-operative care have facilitated the widespread adoption of laparoscopic liver resection (LLR) with encouraging outcomes. Liver cirrhosis (LC) is present in up to 80% of patients with HCC, and adds a further dimension of complexity to LR. Cirrhotic patients have a propensity for greater intraoperative blood loss as well as increased postoperative complications such as refractory ascites and posthepatectomy liver failure. Tumor localization within the fibrotic parenchyma is challenging, giving rise to concerns about resection margin status. Patients are also at higher risk of developing metachronous lesions, which affects long-term survival. Presently, the exact role of LLR in HCC patients with underlying LC is not well-defined. Current evidence suggests that LLR offers a multitude of benefits in the short-term such as reduced blood loss and blood transfusion requirements and lower morbidity, when compared to open resection. Oncologic adequacy and long-term survival do not appear to be compromised. Special consideration must be given for LLR in patients with advanced cirrhosis, or those who require extensive major hepatectomies. We present here a brief review of the literature surrounding LLR for HCC on a background of LC.

Influence of Child-Pugh B7 and B8/9 cirrhosis on laparoscopic liver resection for hepatocellular carcinoma: a retrospective cohort study

BACKGROUND

Laparoscopic liver resection for hepatocellular carcinoma (HCC) in patients with Child-Pugh A cirrhosis has been shown to be beneficial. However, less is known regarding the outcomes of such treatment in patients with Child-Pugh B cirrhosis. We conducted a retrospective study to evaluate the outcomes of laparoscopic liver resection for HCC in patients with Child-Pugh B cirrhosis, focusing on surgical risks, recurrence, and survival.

METHODS

357 patients with HCC who underwent laparoscopic liver resection from 2007 to 2021 were identified from our single-institute database. The patients were divided into three groups by their Child-Pugh score: the Child-Pugh A (n = 280), Child-Pugh B7 (n = 42), and Child-Pugh B8/9 groups (n = 35). Multivariable Cox regression models for recurrence-free survival (RFS) and overall survival (OS) were constructed with adjustment for preoperative and postoperative clinicopathological factors.

RESULTS

The Child-Pugh B8/9 group had a significantly higher complication rate, but the complication rates were comparable between the Child-Pugh B7 and Child-Pugh A groups (Child-Pugh A vs. B7 vs. B8/9: 8.2% vs. 9.6% vs. 26%, respectively; P = 0.010). Compared with the Child-Pugh A group, the risk-adjusted hazard ratios (95% confidence intervals) in the Child-Pugh B7 and B8/9 groups for RFS were 1.39 (0.77-2.50) and 3.15 (1.87-5.31), respectively, and those for OS were 0.60 (0.21-1.73) and 1.80 (0.86-3.74), respectively. There were no significant differences in major morbidities (Clavien-Dindo grade > II) (P = 0.117) or the proportion of retreatment after HCC recurrence (P = 0.367) among the three groups.

CONCLUSION

Among patients with HCC, those with Child-Pugh A and B7 cirrhosis can be good candidates for laparoscopic liver resection in terms of complications and recurrence. Despite poor postoperative outcomes in patients with Child-Pugh B8/9 cirrhosis, laparoscopic liver resection is less likely to interfere with retreatment and can be performed as part of multidisciplinary treatment.

Laparoscopic and open liver resection for hepatocellular carcinoma with Child-Pugh B cirrhosis: multicentre propensity score-matched study

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.

Development of a nomogram to predict outcome after liver resection for hepatocellular carcinoma in Child-Pugh B cirrhosis

BACKGROUND & AIMS

Treatment allocation in patients with hepatocellular carcinoma (HCC) on a background of Child-Pugh B (CP-B) cirrhosis is controversial. Liver resection has been proposed in small series with acceptable outcomes, but data are limited. The aim of this study was to evaluate the outcomes of patients undergoing liver resection for HCC in CP-B cirrhosis, focusing on the surgical risks and survival.

METHODS

Patients were retrospectively pooled from 14 international referral centers from 2002 to 2017. Postoperative and oncological outcomes were investigated. Prediction models for surgical risks, disease-free survival and overall survival were constructed.

RESULTS

A total of 253 patients were included, of whom 57.3% of patients had a preoperative platelet count <100,000/mm³, 43.5% had preoperative ascites, and 56.9% had portal hypertension. A minor hepatectomy was most commonly performed (84.6%) and 122 (48.2%) were operated on by minimally invasive surgery (MIS). Ninety-day mortality was 4.3% with 6 patients (2.3%) dying from liver failure. One hundred and eight patients (42.7%) experienced complications, of which the most common was ascites (37.5%). Patients undergoing major hepatectomies had higher 90-day mortality (10.3% vs. 3.3%; p = 0.04) and morbidity rates (69.2% vs. 37.9%; p <0.001). Patients undergoing an open hepatectomy had higher morbidity (52.7% vs. 31.9%; p = 0.001) than those undergoing MIS. A prediction model for surgical risk was constructed (https://childb.shinyapps.io/morbidity/). The 5-year overall survival rate was 47%, and 56.9% of patients experienced recurrence. Prediction models for overall survival (https://childb.shinyapps.io/survival/) and disease-free survival (https://childb.shinyapps.io/DFsurvival/) were constructed.

CONCLUSIONS

Liver resection should be considered for patients with HCC and CP-B cirrhosis after careful selection according to patient characteristics, tumor pattern and liver function, while aiming to minimize surgical stress. An estimation of the surgical risk and survival advantage may be helpful in treatment allocation, eventually improving postoperative morbidity and achieving safe oncological outcomes.

LAY SUMMARY

Liver resection for hepatocellular carcinoma in advanced cirrhosis (Child-Pugh B score) is associated with a high rate of postoperative complications. However, due to the limited therapeutic alternatives in this setting, recent studies have shown promising results after accurate patient selection. In our international multicenter study, we provide 3 clinical models to predict postoperative surgical risks and long-term survival following liver resection, with the aim of improving treatment allocation and eventually clinical outcomes.

Surgical outcomes between patients with and without a cirrhotic liver undergoing laparoscopic liver resection: A meta-analysis

BACKGROUND

Laparoscopic surgery in patients with liver cirrhosis (CL) is considered to be challenging. Recent studies have shown that laparoscopic liver resection (LLR) is more beneficial of reduced operative stress and postoperative complications in patients with CL.

AIM

A meta-analysis was done to review the currently available published data comparing LLR for patients with CL versus those non-cirrhosis of the liver (NCL).

METHODS

The electronic databases of PubMed, Wiley, Web of Science, Embase, and the Cochrane Library were searched from date of inception to January 29, 2018. Studies reporting a comparison of outcomes and methods of LLR in CL and NCL groups were included. The studies were evaluated using the modified Newcastle-Ottawa Scale.

RESULTS

A total of 1573 patients from six cohort studies were included in final analysis. The CL group had a slightly shorter operative time compared with the NCL group (weighted mean difference [WMD], 18.78min shorter; 95% confidence interval [CI], -43.54-5.98; P=0.14) and delayed hospital stay (WMD, 1.26 days longer; 95% CI, -0.05-2.56; P=0.06). Blood loss, blood transfusion rate, mortality, and conversion rate did not differ significantly between the groups.

CONCLUSIONS

LLR is safe and feasible in the CL compared with the NCL groups. Our present review indicates that LLR should be considered when selecting surgery for patients with CL.

Pure Laparoscopic Versus Open Right Hepatectomy for Hepatocellular Carcinoma in Patients With Cirrhosis: A Propensity Score Matched Analysis

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.

Laparoscopic and robotic approach for hepatocellular carcinoma-state of the art

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.

Laparoscopic right hepatectomy for hepatocellular carcinoma in cirrhotic patient

Hepatocellular carcinoma (HCC) is the sixth most common malignant tumor worldwide and the most common primary liver cancer. Liver resection or liver transplantation is the therapeutic gold standards in patient with HCC related with or without underline liver disease. We present a video case of a 68-year-old woman admitted to our surgical and liver transplantation unit for HCC on liver segment VII. Patient has HCV cirrhosis. Patient underwent to previous right portal vein embolization. Model of end staged liver disease was 7. Body mass index (BMI) was 26.3 and ASA score was 2. Alpha-fetoprotein was 768. According with our multidisciplinary group, we suggest a laparoscopic right hepatectomy for the patient. Operation time was 343 min and blood loss estimation was 200 CC. No transfusion was required. Post-operative course was uneventful, grade 0 of Clavien-Dindo Classification. Patient was discharged in day 7. Pathology report describes a 17 mm × 15 mm HCC grade 4, pT2N0. Laparoscopic liver resection (LLR) for HCC should be performed by dedicated surgical teams in hepatobiliary and laparoscopic surgery. The use of LLR in cirrhotic patients is in many centers proposed as the first-line treatment for HCC or as bridge treatment before liver transplantation.

Liver cirrhosis grading Child-Pugh class B: a Goliath to challenge in laparoscopic liver resection?-prior experience and matched comparisons

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.

Minimally Invasive Surgery of the Liver

Operations on the liver have been undertaken for centuries for numerous indications including trauma, infections, and even for malignancy, but it was not until the past few decades that rates dramatically increased. This expanse in liver operations is due to a multitude of factors, including broader indications as well as improved safety. Our understanding of metastatic disease to the liver, especially colorectal cancer metastases, has vastly amplified the number of patients who would be candidates for hepatic resections and liver-directed therapies. We will focus our discussion here on planned minimally invasive operations for benign and malignant tumors as the majority of the literature relates to this setting.

Laparoscopic liver resection for hepatocellular carcinoma in cirrhotic patients: single center experience of 90 cases

BACKGROUND

Hepatocellular carcinoma (HCC) with or without underlying liver disease can be treated by surgical resection. The aim of this study was to evaluate the feasibility, morbidity and mortality of a laparoscopic approach in cirrhotic patients with HCC.

METHODS

From 2004 to September 2014, 90 patients underwent a laparoscopic liver resection (LLR) for HCC. Data were collected in a prospectively maintained database since 2001. Preoperative patient evaluation was based on a multidisciplinary team meeting assessment.

RESULTS

Median age was 63 years; 67 (74.4%) patients were male. Median body mass index (BMI) was 26.7. Underlying liver disease was known in 68 patients: in 46 patients' hepatitis C virus (HCV)-related, in 15 patients to hepatitis B virus (HBV)-related, in 5 patients alcohol-related. Child-Pugh Score was of grade A in 85 patients and of grade B in 5 patients; 63 patients had a Model for End-stage Liver Disease (MELD) <10 and 27 patients MELD >10. A total of 18 left lateral sectionectomies, 1 left hepatectomy and 71 wedge resections or segmentectomies were performed. Conversion to laparotomy was necessary in 7 (7.7%) patients (five cases for bleeding and two cases for oncological reasons). In 90 patients, 98 HCC nodules were resected: 79 patients had one nodule, 8 patients had two nodules and 1 patient had three nodules. HCC nodules medium diameter was 29 mm (range, 4-100 mm) with median value of 25 mm. Tumor margins distance was 16 mm (range, 0-35 mm) with a median of 5 mm. Seventy nodules were located within the anterior sectors and 28 nodules within the posterior sectors.

CONCLUSIONS

LLR for HCC can be performed with acceptable morbidity in patients with underlying liver disease. The use of laparoscopic surgery in cirrhotic patients may be proposed as the first-line treatment for HCC or as bridge treatment before liver transplantation.

Laparoscopic first step approach in the two stage hepatectomy

Resection is the gold standard therapeutic option for patients with colorectal liver metastases. However, only 20-30% of patients are resectable. In patients with a concomitant future liver remnant (FLR) less than 25-30%, a single stage resection is not feasible. The aim of this study is to evaluate the feasibility and the rates of morbidity and mortality of the laparoscopic approach in the first-step of two stage hepatectomy. From 2004 to March 2014, 73 patients underwent a two stage hepatectomy: of these, four underwent a totally laparoscopic first step [wedge left liver resection and right portal vein ligation (PVL)]. All the patients were male. Median age was 55 years. One patient underwent an atypical wedge resection of segment II-III and a laparoscopic PVL (LPVL), one patient had a first wedge resection of segment II and LPVL, and two patients underwent a wedge resection of segment III and LPVL. First step surgical mean time was 189 (range, 160-244) min, mean blood loss was 22 (range, 0-50) cc. No transfusion was required in this series. The results of our study demonstrate that the first step of hepatic resection and PVL is feasible with a laparoscopic approach in patients with bilobar liver metastases.

Total abdominal approach for postero-superior segments (7, 8) in laparoscopic liver surgery: a multicentric experience

Laparoscopic liver resections are frequently performed for peripheral lesions located in the antero-inferior segments. Resection of postero-superior segments is more demanding and dangerous than other segmentectomies, resulting in a longer operation time and increased blood loss. To reduce technical challenges, some authors advocated a modified surgical approach for these segments with the patient placed in the left lateral decubitus with the right arm suspended and suggested technical variations like the use of an additional intercostal trocar, the placement of one or two additional trans-thoracic trocars, a hand-assisted approach or a hybrid method with a median laparotomy. In the present series of 88 patients from four hepatobiliary centers with high volume of activity in Italy, a standard lithotomic position has been routinely used without the need for left lateral decubitus or semi-prone position and through abdominal wall without use of trans-thoracic trocars. This approach allows a more comfortable use of the Pringle maneuver that we used routinely in hepatic resection for PS segments; and, a very short time is needed for conversion, whenever it is required. In our series, laparoscopic resection of liver tumors located in the postero-superior segments of the liver with a total abdominal approach is technically feasible and safe with short-term results similar to other laparoscopic liver resections.