Perioperative and oncologic outcomes of minimally invasive liver resection for colorectal metastases: A case-control study of 130 patients

The minimally invasive approach confers improved outcomes in frail cancer patients undergoing hepatectomy: an American College of Surgeons National Surgical Quality Improvement Program analysis

BACKGROUND

Morbidity for liver resection has decreased, and frail patients are undergoing surgery. The effect of minimally invasive liver resection (MILR) is unknown. This study aimed to evaluate the effect of MILR on the outcomes in frail patients.

METHODS

Elective hepatectomies from the 2014-2020 American College of Surgeons National Surgical Quality Improvement Program hepatectomy-specific Participant User File were reviewed. The 5-factor modified frailty index (mFI-5) was used. It includes diabetes mellitus, hypertension, functional status, heart failure, and dyspnea. Patients were considered frail if their mFI-5 score was ≥2.

RESULTS

A total of 3116 patients were included: 2117 (67.9%) in the minor hepatectomy group and 999 (32%) in the major hepatectomy group. There were 2254 open cases and 862 MILRs. Postoperatively, patients in the minor hepatectomy group who underwent MILR had lower rates of prolonged length of stay (LOS), nonhome discharge, transfusion, major complications, and minor complications (P < .05). Postoperatively, patients in the major hepatectomy group who underwent MILR had lower rates of prolonged LOS and any complication (P < .05). In the minor hepatectomy group, MILR remained independently predictive of lower rates of prolonged LOS (odds ratio [OR], 0.34; 95% CI, 0.28-0.42), nonhome discharge (OR, 0.58; 95% CI, 0.41-0.84), transfusion (OR, 0.72; 95% CI, 0.54-0.96), major complication (OR, 0.78; 95% CI, 0.62-1.00), and any complication (OR, 0.73; 95% CI, 0.58-0.92). In the major hepatectomy group, MILR remained independently predictive of prolonged LOS (OR, 0.60; 95% CI, 0.40-0.89).

CONCLUSION

MILR resulted in lower rates of complications in the minor hepatectomy group and shorter LOS in the major hepatectomy group. The minimally invasive approach to hepatectomy may benefit frail patients with cancer.

Minimally invasive versus open hepatectomy for the resection of colorectal liver metastases: a systematic review and meta-analysis

BACKGROUND

While surgical resection has a demonstrated utility for patients with colorectal liver metastases (CRLM), it is unclear whether minimally invasive surgery (MIS) or an open approach should be used. This review sought to assess the efficacy and safety of MIS versus open hepatectomy for isolated, resectable CRLM when performed separately from (Key Question (KQ) 1) or simultaneously with (KQ2) the resection of the primary tumor.

METHODS

PubMed, Embase, Google Scholar, Cochrane CENTRAL, International Clinical Trials Registry Platform (ICTRP), and ClinicalTrials.gov databases were searched to identify both randomized controlled trials (RCTs) and non-randomized comparative studies published during January 2000-September 2020. Two independent reviewers screened literature for eligibility, extracted data from included studies, and assessed internal validity using the Cochrane Risk of Bias 2.0 Tool and the Newcastle-Ottawa Scale. A random-effects meta-analysis was performed using risk ratios (RR) and mean differences (MD).

RESULTS

From 2304 publications, 35 studies were included for meta-analysis. For staged resections, three RCTs and 20 observational studies were included. Data from RCTs indicated MIS having similar disease-free survival (DFS) at 1-year (RR 1.03, 95%CI 0.70-1.50), overall survival (OS) at 5-years (RR 1.04, 95%CI 0.84-1.28), fewer complications of Clavien-Dindo Grade III (RR 0.62, 95%CI 0.38-1.00), and shorter hospital length of stay (LOS) (MD -6.6 days, 95%CI -10.2, -3.0). For simultaneous resections, 12 observational studies were included. There was no evidence of a difference between MIS and the open group for DFS-1-year, OS-5-year, complications, R0 resections, blood transfusions, along with lower blood loss (MD -177.35 mL, 95%CI -273.17, -81.53) and shorter LOS (MD -3.0 days, 95%CI -3.82, -2.17).

CONCLUSIONS

Current evidence regarding the optimal approach for CRLM resection demonstrates similar oncologic outcomes between MIS and open techniques, however MIS hepatectomy had a shorter LOS, lower blood loss and complication rate, for both staged and simultaneous resections.

OUP accepted manuscript

Background

Laparoscopic liver resection (LLR) is a highly demanding procedure with great variability. Previously published randomized trials have proven oncological safety of laparoscopic liver resection (LLR) as compared to open surgery. However, these were started after the learning curve (LC) was established. This leaves the question of whether the LC of LLR in the early laparoscopic era has affected the survival of patients with colorectal liver metastasis (CRLM).

Methods

All consecutive LLRs performed by a single surgeon between 2000 and 2019 were retrospectively analysed. A risk-adjusted cumulative sum (RA-CUSUM) chart for conversion rate and the log regression analysis of the blood loss identified two phases in the LC. This was then applied to patients with CRLM, and the two subgroups were compared for recurrence-free (RFS) and overall survival (OS). The analysis was repeated with propensity score-matched (PSM) groups

Results

A total of 286 patients were included in the LC analysis, which identified two distinct phases, the early (EP; 68 patients) and the late (LP; 218 patients) phases. The LC was applied to 192 patients with colorectal liver metastasis (EPc, 45 patients; LPc, 147 patients). For patients with CRLM, R0 resection was achieved in 93 per cent: 100 per cent in the EPc group and 90 per cent in the LPc group (P = 0.026). Median OS and RFS were 60 and 16 months, respectively. The 5-year OS and RFS were 51 per cent and 32.7 per cent, respectively. OS (hazard ratio (h.r.) 0.78, 95 per cent confidence interval (c.i.) 0.51 to 1.2; P = 0.286) and RFS (h.r. 0.94, 95 per cent c.i. 0.64 to 1.37; P = 0.760) were not compromised by the learning curve. The results were replicated after PSM.

Conclusion

In our experience, the development of a laparoscopic liver resection programme can be achieved without adverse effects on the long-term survival of patients with CRLM.

Laparoscopic liver resection for colorectal liver metastases - short- and long-term outcomes: A systematic review

BACKGROUND

For well-selected patients and procedures, laparoscopic liver resection (LLR) has become the gold standard for the treatment of colorectal liver metastases (CRLM) when performed in specialized centers. However, little is currently known concerning patient-related and peri-operative factors that could play a role in survival outcomes associated with LLR for CRLM.

AIM

To provide an extensive summary of reported outcomes and prognostic factors associated with LLR for CRLM.

METHODS

A systematic search was performed in PubMed, EMBASE, Web of Science and the Cochrane Library using the keywords "colorectal liver metastases", "laparoscopy", "liver resection", "prognostic factors", "outcomes" and "survival". Only publications written in English and published until December 2019 were included. Furthermore, abstracts of which no accompanying full text was published, reviews, case reports, letters, protocols, comments, surveys and animal studies were excluded. All search results were saved to Endnote Online and imported in Rayyan for systematic selection. Data of interest were extracted from the included publications and tabulated for qualitative analysis.

RESULTS

Out of 1064 articles retrieved by means of a systematic and grey literature search, 77 were included for qualitative analysis. Seventy-two research papers provided data concerning outcomes of LLR for CRLM. Fourteen papers were eligible for extraction of data concerning prognostic factors affecting survival outcomes. Qualitative analysis of the collected data showed that LLR for CRLM is safe, feasible and provides oncological efficiency. Multiple research groups have reported on the short-term advantages of LLR compared to open procedures. The obtained results accounted for minor LLR, as well as major LLR, simultaneous laparoscopic colorectal and liver resection, LLR of posterosuperior segments, two-stage hepatectomy and repeat LLR for CRLM. Few research groups so far have studied prognostic factors affecting long-term outcomes of LLR for CRLM.

CONCLUSION

In experienced hands, LLR for CRLM provides good short- and long-term outcomes, independent of the complexity of the procedure.

Long-Term and Oncologic Outcomes of Robotic Versus Laparoscopic Liver Resection for Metastatic Colorectal Cancer: A Multicenter, Propensity Score Matching Analysis

BACKGROUND

To assess long-term oncologic outcomes of robotic-assisted liver resection (RLR) for colorectal cancer (CRC) metastases as compared to a propensity-matched cohort of laparoscopic liver resections (LLR). Although safety and short-term outcomes of RLR have been described and previously compared to LLR, long-term and oncologic data are lacking.

METHODS

A retrospective study was performed of all patients who underwent RLR and LLR for CRC metastases at six high-volume centers in the USA and Europe between 2002 and 2017. Propensity matching was used to match baseline characteristics between the two groups. Data were analyzed with a focus on postoperative and oncologic outcomes, as well as long-term recurrence and survival.

RESULTS

RLR was performed in 115 patients, and 514 patients underwent LLR. Following propensity matching 115 patients in each cohort were compared. Perioperative outcomes including mortality, morbidity, reoperation, readmission, intensive care requirement, length-of-stay and margin status were not statistically different. Both prematching and postmatching analyses demonstrated similar overall survival (OS) and disease-free survival (DFS) between RLR and LLR at 5 years (61 vs. 60% OS, p = 0.87, and 38 vs. 31% DFS, p = 0.25, prematching; 61 vs. 60% OS, p = 0.78, and 38 vs. 44% DFS, p = 0.62, postmatching).

CONCLUSIONS

Propensity score matching with a large, multicenter database demonstrates that RLR for colorectal metastases is feasible and safe, with perioperative and long-term oncologic outcomes and survival that are largely comparable to LLR.

The actual management of colorectal liver metastases

Colorectal cancer is one of the most frequent cancers in the world and between 50% and 60% of patients will develop colorectal liver metastases (CRLM) during the disease. There have been great improvements in the management of CRLM during the last decades. The combination of modern chemotherapeutic and biological systemic treatments with aggressive surgical resection strategies is currently the base for the treatment of patients considered unresectable until few years ago. Furthermore, several new treatments for the local control of CRLM have been developed and are now part of the arsenal of multidisciplinary teams for the treatment of these complex patients. The aim of this review was to summarize and update the management of CRLM, its controversies and relevant evidence.

Highlights, limitations and future challenges of laparoscopic resection for colorectal liver metastases

The liver is the most common site for metastatic colorectal cancer (CRLM). Despite advances in oncologic treatment, resection of metastases is still the only curative option. Although laparoscopic surgery for primary colorectal cancer is well documented and widely used, laparoscopic surgery for liver metastases has developed more slowly. However, in spite of some difficulties, laparoscopic approach demonstrated strong advantages including minimal parietal damage, decreased morbidity (reduced blood loss and need for transfusion, fewer pulmonary complications), and simplification of subsequent iterative hepatectomy. Up to now, more than 9 000 laparoscopic procedures have been reported worldwide and long-term results in colorectal liver metastases seem comparable to the open approach. Only one recent randomized controlled trial has compared the laparoscopic and the open approach. The purpose of the present update was to identify the barriers limiting widespread acceptance of laparoscopic approach, the benefits and the limits of laparoscopic hepatectomies in CRLM.

A systematic review and meta-analysis comparing the short- and long-term outcomes for laparoscopic and open liver resections for liver metastases from colorectal cancer

BACKGROUND

The laparoscopic approach to liver resection has experienced exponential growth in recent years. However, evidence-based guidelines are needed for its safe future progression. The main aim of our study was to perform a systematic review and meta-analysis comparing the short- and long-term outcomes of laparoscopic and open liver resections for colorectal liver metastases (CRLM).

METHODS

To identify all the comparative manuscripts between laparoscopic and open liver resections for CRLM, all published English language studies with more than ten cases were screened. In addition to the primary meta-analysis, 3 specific subgroup analyses were performed on patients undergoing minor-only, major-only and synchronous resections. The quality of the studies was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) methodology and Newcastle-Ottawa Score.

RESULTS

From the initial 194 manuscripts identified, 21 were meta-analysed, including results from the first randomized trial comparing open and laparoscopic resections of CRLM. Five of these were specific to patients undergoing a synchronous resection (399 cases), while six focused on minor (3 series including 226 cases) and major (3 series including 135 cases) resections, respectively. Thirteen manuscripts compared 2543 cases but could not be assigned to any of the above sub-analyses, so were analysed independently. The majority of short-term outcomes were favourable to the laparoscopic approach with equivalent rates of negative resection margins. No differences were observed between the approaches in overall or disease-free survival at 1, 3 or 5 years.

CONCLUSION

Laparoscopic liver resection for CRLM offers improved short-term outcomes with comparable long-term outcomes when compared to open approach.

Hepatic resection of solitary HCC in the elderly: A unique disease in a growing population

BACKGROUND

Management of elderly patients with solitary hepatocellular carcinoma (sHCC) is challenging with perceived clinicopathologic differences driving treatment options. We sought to determine factors predictive of disease control and survival after hepatic resection of sHCC in elderly patients.

METHODS

We identified n = 45 elderly patients (³≥65 yo) with sHCC treated with hepatic resection alone from our prospective database from 2003-16. Clinicopathologic data were analyzed and survival was assessed from the time of hepatic resection.

RESULTS

The median age was 75-years-old. Less than half of patients (47%) had viral hepatitis. At resection, the median Child-Pugh score was A6, median tumor size 5 cm, and mean AFP of 1050 (ng/mL). Major hepatectomy was performed in 23 patients (51%) with R0 resection achieved in 96%. Two patients (4%) had Grade III complications with no mortalities at 30 days and one death (2%) at 90-days. After R0 resection 44% (n = 20) had intrahepatic recurrence at a median of 32 months (95% CI: 15-46) with 20% (n = 9) developing extrahepatic recurrence at a median of 78 months (95% CI: 78-.). The median survival was 72 months (95% CI: 30-108 months). For patients with at least 3 years of follow-up, the 1-, 3-, and 5-year overall survival was 74%, 59%, and 50%, respectively. Mortality was associated with higher AFP and lower Prognostic Nutritional Index (PNI).

CONCLUSION

Carefully selected elderly patients with sHCC appear to have unique disease that is amenable to hepatic resection with low morbidity and mortality with excellent overall and recurrence-free survival.

Laparoscopic versus open liver resection for colorectal liver metastases: a systematic review

BACKGROUND

Laparoscopic liver resection (LLR) has been proposed as a safe and feasible treatment option for colorectal liver metastasis (CRLM). However, the short-term and oncologic outcomes of LLR versus open liver resection (OLR) for CRLM have not been adequately assessed. Thus, we herein provide an updated systematic review comparing short-term and oncologic outcomes of CRLM patients undergoing LLR versus OLR.

METHODS

A systematic literature search was performed in the Pubmed, Embase, and Cochrane Library databases (until November 2, 2016) with a limitation to the publications in English. Quality assessment was performed based on the modification of the Newcastle-Ottawa Scale. Dichotomous data were calculated by odds ratio (OR), and continuous data were calculated by weighted mean difference (WMD) with 95% confidence intervals (CIs).

RESULTS

A total of 28 studies enrolling 4591 patients with CRLM were included. With respect to short-term outcomes, patients in LLR group showed significantly reduced blood loss (WMD: -143.64; 95% CI: -180.56 to -106.73; I2 = 86%; P < 0.001), lower operative transfusion requirement (OR: 0.40; 95% CI: 0.30-0.53; I2 = 0%; P < 0.001), shorter hospital stay (WMD: -2.47; 95% CI: -2.99 to -1.94; I2 = 82%; P < 0.001), reduced overall postoperative morbidity (OR: 0.53; 95% CI: 0.42-0.66; I2 = 38%; P < 0.001) and reduced severe morbidity (OR: 0.44; 95% CI: 0.32-0.60; I2 = 35%; P < 0.001). Regarding oncologic outcomes, there were no significant differences between the two surgical procedures in recurrence and 1-, 3-, and 5-overall survival and disease-free survival except for slightly higher R0 resection rate in LLR group was slightly higher than that of OLR group (OR: 1.43; 95% CI: 1.03-1.97; I2 = 37%; P = 0.03).

CONCLUSIONS

LLR should be the standard approach for selected patients with CRLM, and further research should focus on determining which patients would benefit most from LLR.