Laparoscopic management of benign liver diseases: where are we?

Mucin-producing hepatic cystic neoplasms: an uncommon but challenging disease often misdiagnosed and mismanaged

Background: Mucin-producing hepatic cystic neoplasms (MHCN) are uncommon and potentially malignant.Methods: Nine MHCN were encountered in our centre for over 32 years. Patients' clinical, biological, radiological and pathological features were reviewed. Lesions were classified into Mucinous Cystic Neoplasms (MCN) and Intraductal Papillary Neoplasms of the Bile duct (IPNB) (WHO 2010 classification).Results: Five MCN and 4 IPNB were reviewed. Serum and intracystic tumour markers were insufficient to diagnose malignancy. Complications were encountered in five out of nine patients (56%), mean symptom duration was 26 months (range: 1-132). Three patients were mismanaged pre-referral. Radiological features enabled preoperative diagnosis in eight out of nine patients (89%). Greater tumour size, unilocular lesion and mural nodularity indicated malignancy. Radical tumour excision was achieved in eight patients. One IPNB patient was misdiagnosed and underwent unroofing. For 103 months median follow-up, five out of six patients with benign tumours were alive and disease-free, whereas the misdiagnosed IPNB recurred with fatal malignant transformation seven years later. Among the three patients with malignancies (median follow-up: 77 months), two IPNB died, one from cancer recurrence and one from unrelated causes, whereas the malignant MCN was alive and disease-free.Conclusions: Appropriate MHCN diagnosis is crucial, yet it is often misdiagnosed and mismanaged. The prognosis after complete excision is favourable.

Elective laparoscopic deroofing to treat the spontaneous rupture of a large simple liver cyst: a case report

Background

The spontaneous rupture of nonparasitic liver cysts (NLC) is sometimes seen in clinical practice. However, there are no guidelines that describe the optimal treatment strategy and the surgical indications for an NLC rupture due to a small number of reports. Here, we present a case who underwent elective laparoscopic deroofing to treat a spontaneously ruptured NLC that had undergone conservative treatment.

Case presentation

A 67-year-old woman was referred to our hospital for the evaluation of acute abdominal pain after the conservative treatment of an NLC at another hospital. She had stable vital signs and no abdominal rigidity. We performed an elective laparoscopic deroofing following an examination of the cyst relative to the bile ducts and the patient’s general condition. Computed tomography (CT) and magnetic resonance imaging (MRI) showed that there was no solid mass in the cyst. During the laparoscopic surgery, the cyst wall was resected and the back wall of the cyst was incinerated using an inverse-opal-structure electrode. The patient’s postoperative course was stable without any complications.

Conclusions

We succeeded the conservative therapy and the elective laparoscopic surgery for ruptured of NLC. However, elective surgery in spontaneously ruptured NLC with intraabdominal infection or hemorrhage is still challenging.

Symptomatic abdominal simple cysts: is percutaneous sclerotherapy with hypertonic saline and bleomycin a treatment option?

Aim. To evaluate the feasibility of percutaneous sclerotherapy of symptomatic simple abdominal cysts, using hypertonic saline and bleomycin, as an alternative to surgery. Materials and Methods. This study involved fourteen consecutive patients (ten women, four men, mean age: 59.2 y) with nineteen symptomatic simple cysts (liver n = 14, kidney n = 3, and adrenal n = 2) treated percutaneously using a modified method. Initially CT-guided drainage was performed; the next day the integrity of the cyst/exclusion of extravasation or communications was evaluated under fluoroscopy, followed by two injections/reabsorptions of the same quantity of hypertonic NaCl 15% solution and three-time repetition of the same procedure with the addition of bleomycin. The catheter was then removed; the patients were hospitalized for 12 hours and underwent follow-ups on 1st, 3rd, 6th, and 12th months. Cyst's volumes and the reduction rate (%) were calculated in each evaluation. Results. No pain or complications were noted. A significant cyst's volume reduction was documented over time (P < 0.001). On the 12th month 17 cysts disappeared and two displayed a 98.7% and 68.9% reduction, respectively. Conclusion. This percutaneous approach constitutes a very promising nonsurgical alternative for patients with symptomatic simple cyst, without complications under proper precautions, leading to eliminating the majority of cysts.

National trends in the use of surgery for benign hepatic tumors in the United States

BACKGROUND

The widespread use of diagnostic imaging has led to an increase in the incidence and diagnosis of benign liver tumors. The objective of this study was to define the overall use and temporal trends of operative procedures for benign liver tumors using a nationally representative cohort.

METHODS

All patients who underwent liver surgery for benign liver tumors between 2000 and 2011 were identified from the Nationwide Inpatient Sample database. Trends in annual volume of liver procedures were analyzed using the average annual percent change (AAPC) assessed by joinpoint analysis.

RESULTS

There were 2,489 open (94.5%) and 144 (5.5%) minimally invasive surgical (MIS) procedures. Partial hepatectomy accounted for 43.8% of all cases (n = 1,153). Surgery for patients with benign liver tumors increased from 156 in 2000 to 272 in 2011 (AAPC, 5.8%; 95% CI, 3.2-8.6%). There was decline in the relative use of open operative procedures from 98.1% in 2000 to 92.3% in 2011 (AAPC, -0.4%; 95% CI, -0.7 to -0.1%). In contrast, the proportion of MIS procedures increased from 1.9% in 2000 to 7.7% in 2011 (AAPC, 7.4%; 95% CI, 1.9-13.3%). The median duration of stay among all patients was 5 days (interquartile range, 4-7; 5 days [open] vs 3 days [MIS]; P < .001). Inpatient mortality was 0.6% (n = 15 [open] vs n = 0 [MIS]; P = .43) and did not change during the study period (P > .05).

CONCLUSION

Overall volume of surgical management of benign liver tumors has increased substantially over the past decade. There has been a relative shift away from open procedures toward MIS procedures.

Current treatment status of polycystic liver disease in Japan

AIM

Polycystic liver disease (PLD) is a genetic disorder characterized by the progressive development of multiple liver cysts. No standardized criteria for the selection of treatment exist because PLD is a rare condition and most patients are asymptomatic. We here aimed to clarify the status of treatment and to present a therapeutic strategy for PLD in Japan.

METHODS

From 1 June 2011 to 20 December 2011, we administered a questionnaire to 202 PLD patients from 86 medical institutions nationwide.

RESULTS

The patients included 45 men and 155 women, and the median age was 63 years. Two hundred and eighty-one treatments were performed for these patients, as follows: cyst aspiration sclerotherapy (AS) in 152 cases, cyst fenestration (FN) in 53, liver resection (LR) in 44, liver transplantation (LT) in 13 and other treatments in 19. For cases of type I PLD (mild form) according to Gigot's classification, the therapeutic effects of AS, FN and LR were similar. For type II (moderate form), LT demonstrated the best therapeutic effects, followed by LR and FN. For type III (severe form), the effects of LT were the best. The incidences of complications were 23.0% in AS, 28.4% in FN, 31.8% in LR and 61.5% in LT.

CONCLUSION

Considering the therapeutic effects and complications, AS, LR and LT showed good results for type I, type II and type III PLD, respectively. However, LT for PLD was performed in a small number of patients. In Japan, the transplantation therapy is expected to be common in the future.

Polycystic liver disease

A widespread use of ultrasound (US) examination is contributing to an increase in the diagnosis of renal and hepatic cysts. However, the vast majority of these lesions are benign with an indolent course during the patient's lifespan. Adult polycystic kidney disease (APKD) is one of the most common diagnosed entities. APKD is a genetic disease defined by the presence of multiple kidney cysts, occasionally accompanied by hepatic cysts. The presence of hepatic cysts sparing kidneys is very rare and thereby must be assumed as a different clinical entity. This article describes a case of an exuberant hepatomegaly due to the presence of isolated multiple hepatic cysts without renal involvement.

Long-term outcome after laparoscopic fenestration of simple liver cysts

BACKGROUND

Simple liver cysts (LCs) represent the most common benign liver disease, with a prevalence of 3-5%. Laparoscopic fenestration is considered the best treatment for symptomatic LCs, but few studies have analyzed the rate or type of recurrence during a long-term follow-up period (>5 years).

METHODS

Between January 2000 and December 2010, 47 patients underwent laparoscopic fenestration for simple LCs. The indications were symptoms for 42 patients and an uncertain diagnosis for five patients. The follow-up assessment consisted of regular patient evaluations, with results of laboratory data and liver ultrasound.

RESULTS

Conversion to laparotomy was not necessary in any case. The postoperative mortality and morbidity rates were nil. The mean follow-up period was 67 months (range 12-142 months), and 26 patients (55.3%) had a follow-up period longer than 5 years. During the follow-up period, 40 patients (85.1%) did not present with any type of recurrence. The overall recurrence rate was 14.9% (seven patients) based on five patients (10.6%) with radiologic asymptomatic recurrences detected by ultrasound or computed tomography (CT) scan and two patients (4.3%) with clinicoradiologic symptomatic recurrences. Both symptomatic recurrences involved LCs located in the right posterior segments.

CONCLUSIONS

Laparoscopic fenestration provided complete relief of symptoms for about 95% of patients with simple LCs. Recurrence after surgery was experienced by 14.9% of the patients, but only in 4.3% (two patients) was this recurrence symptomatic requiring a second treatment. The site of recurrence was more frequently in the right posterior segments. Laparoscopic fenestration of symptomatic LCs can be considered a safe and effective procedure that can yield good long-term results.

Focal Nodular Hyperplasia and Hepatocellular Adenoma around the World Viewed through the Scope of the Immunopathological Classification

Focal nodular hyperplasia (FNH) and hepatocellular adenoma (HCA) are benign hepatocellular tumors. The risk of bleeding and malignant transformation of HCA are strong arguments to differentiate HCA from FNH. Despite great progress that has been made in the differential radiological diagnosis of the 2 types of nodules, liver biopsy is sometimes necessary to separate the 2 entities. Identification of HCA subtypes using immunohistochemical techniques, namely, HNF1A-inactivated HCA (35-40%), inflammatory HCA (IHCA), and beta-catenin-mutated inflammatory HCA (b-IHCA) (50-55%), beta-catenin-activated HCA (5-10%), and unclassified HCA (10%) has greatly improved the diagnostic accuracy of benign hepatocellular nodules. If HCA malignant transformation occurs in all HCA subgroups, the risk is by far the highest in the β -catenin-mutated subgroups (b-HCA, b-IHCA). In the coming decade the management of HCA will be more dependent on the identification of HCA subtypes, particularly for smaller nodules (<5 cm) in terms of imaging, follow-up, and resection.

Managements of simple liver cysts: ablation therapy versus cyst unroofing

Backgrounds/Aims

Simple liver cysts were easily recognizable with the advanced imaging procedures, such as ultrasound and computed tomography scan. A large cyst or significant symptoms were indications for the treatments. Ablation therapy with sclerotic agents was effective, but there were several complications including severe pain. With the surgical cyst unroofing method introduced, we compared the cyst unroofing method and ablation therapy.

Methods

Between March 1997 and May 2011, we performed treatments of simple liver cysts in 27 patients. There were 23 women and 4 men (age range: 42-84 years; mean age: 64 years). The cyst unroofing was undergone with laparoscopic (n=13) and open technique (n=1). The ablation therapy was performed with ethanol (n=13) and acetic acid (n=1).

Results

The usual symptoms of the liver cysts were abdominal mass (n=7), indigestion (n=4), abdominal discomfort (n=3), and the increasing size of the cysts (n=4). The mean diameter of the cysts was 10.9 cm. The cyst unroofing method was performed effectively in 14 patients. One patient had bleeding during operation, and was converted to the open technique. One patient had a bile leak from the cyst, but it was successfully closed with the laparoscopic technique. Among the 14 cases with the ablation therapy, there were 4 complications: hematoma (n=1); cyst leaking during aspiration (n=2); acute renal failure (n=1); and death due to acetic acid intoxication (n=1).

Conclusions

Laparoscopic cyst unroofing was more effective and safer in management than the ablation therapy in simple liver cysts.

Hemorrhagic hepatic cyst: report of a case and review of the literature with emphasis on clinical approach and management

OBJECTIVE

Hemorrhage within a hepatic cyst (hemorrhagic hepatic cyst, HHC) is a complication of liver cysts that is difficult to differentiate from other neoplastic entities on imaging. Even when accurately diagnosed, there has been a lack of consensus on the optimal treatment strategy. After presenting our experience with a patient treated via laparoscopy, we aimed to conduct a review of the literature on HHCs.

METHODS

A computerized search in Medline, PubMed, Google Scholar, and The Cochrane Collaboration was carried out for journal articles or abstracts published from 1950 to 2011.

RESULTS

A total of 24 patients with HHCs were identified from 1983 to 2011. The cohort had an even gender distribution with a mean age of 62.7 years. Most patients presented with abdominal pain (80 %), while three (14 %) patients were asymptomatic at the time of presentation. CT imaging and ultrasound were unable to accurately diagnose HHC, whereas hyperintensity on MRI was a reliable diagnostic tool. Three (13 %) patients were managed conservatively with observation. Seven (30 %) patients had percutaneous transhepatic drainage. Among these, two patients experienced recurrence that required repeat treatment. Two (9 %) patients underwent open unroofing of their HHC and one (4 %) laparoscopically, without recurrences. Seven (30 %) patients underwent hepatic resection, whereas six (26 %) patients had a cyst enucleation for their HHCs. All patients had uneventful recoveries, with a mean follow-up of 25 months.

CONCLUSIONS

MRI is a reliable diagnostic tool in the setting of an HHC. Laparoscopic unroofing of HHCs may represent a less morbid and safe treatment modality with low recurrence rates. Given the low level of clinical evidence available so far, these results should be interpreted with caution.

Hepatocellular adenoma: an excellent indication for laparoscopic liver resection

OBJECTIVES

Laparoscopic resection for benign liver disease has gained wide acceptance in recent years and hepatocellular adenoma (HA) seems to be an appropriate indication. This study aimed to discuss diagnosis and treatment strategies, and to assess the feasibility, safety and outcomes of pure laparoscopic liver resection (LLR) in a large series of patients with HA.

METHODS

Of 88 patients who underwent pure LLR, 31 were identified as having HA. Diagnosis was based on radiological evaluation and resections were performed for lesions measuring >5.0 cm.

RESULTS

The sample included 29 female and two male patients. Their mean age was 33.2 years. A total of 27 patients had a single lesion, one patient had two and one had four lesions. The two remaining patients had liver adenomatosis. Mean tumour size was 7.5 cm. Three right hepatectomies, 17 left lateral sectionectomies and 11 wedge resections or segmentectomies were performed. There was no need for blood transfusion or conversion to open surgery. Postoperative complications occurred in two patients. Mean hospital stay was 3.8 days.

CONCLUSIONS

Hepatocellular adenoma should be regarded as an excellent indication for pure LLR. Pure LLR is safe and feasible and should be considered the standard of care for the treatment of HA when performed by surgeons with experience in liver and laparoscopic surgery.

Systematic review: the pathophysiology and management of polycystic liver disease

BACKGROUND

Polycystic liver diseases (PCLD) represent a group of genetic disorders in which cysts occur solely in the liver, or together with renal cysts. Most of the patients with PCLD are asymptomatic, however, in some patients, expansion of liver cysts causes invalidating abdominal symptoms.

AIM

To provide a systemic review on the pathophysiology and management of PCLD.

METHODS

A PubMed search was undertaken to identify relevant literature using search terms including polycystic liver disease, pathophysiology, surgical and medical management.

RESULTS

The most common complication in patients with PCLD is extensive hepatomegaly, which may lead to malnutrition and can be lethal. Conservative surgical approaches are only partially effective and do not change the natural course of the disease. Liver transplantation has been successfully performed in PCLD, however, in an era of organ shortage, medical management needs to be evaluated. A better understanding of the pathophysiology and the availability of animal models have already identified promising drugs. Abnormalities in cholangiocyte proliferation/apoptosis and enhanced fluid secretion are key factors in the pathophysiology. It has been demonstrated in rodents and in humans that somatostatin analogues diminish liver volume. The role of the inhibitors of the mammalian target of rapamycin (mTOR) in the management of PCLD is still under investigation.

CONCLUSIONS

The exact pathophysiology of polycystic liver disease still remains unclear. In symptomatic patients, none of the currently available surgical options except liver transplantation have been shown to change the natural course of the disease. The use of somatostatin analogues has been shown to diminish liver volume.

Laparoscopic fenestration of non-parasitic liver cysts and health-related quality of life assessment

Although laparoscopic fenestration has become an established treatment in symptomatic liver cyst patients in the recent years, the success of surgical treatment cannot only be evaluated by post-operative morbidity and mortality. Therefore, the aim of this study was to analyze the safety of laparoscopic fenestration of non-parasitic liver cysts and to assess the impact of this therapy on patients' quality of life. A total of 43 patients who underwent laparoscopic fenestration of non-parasitic liver cysts at our center were included in this study. Post-operative course was assessed and patients' quality of life was evaluated before surgery and at present time using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (QLQ C-30). The results were that, post-operative morbidity and mortality rates were 0%. After a median follow-up of 49 months (19-97 months) the recurrence rate was 11.1% for simple liver cysts (SLC) and 42.9% for polycystic liver disease (PCLD). Thirty-one out of 43 patients (72.1%) completed the EORTC C-30 questionnaire. There was highly significant post-operative improvement in global health status (p < 0.001) as well as in physical (p = 0.002), role (p = 0.004), emotional (p = 0.003) and social (p = 0.001) functioning. Furthermore, a significant reduction of symptoms could be shown for pain (p < 0.001), nausea and vomiting (p = 0.001), appetite loss (p = 0.006), insomnia (p = 0.04) and fatigue (p = 0.025). To conclude, laparoscopic fenestration of symptomatic non-parasitic liver cysts is a safe procedure with good long-term results and the patients' benefit of this intervention is excellent as shown by highly significant improvement in patients' quality of life.

Laparoscopic resection for liver tumors: initial experience in a single center

BACKGROUND

Laparoscopic liver resections are 1 of the most complex procedures in hepatobiliary surgery. During the last 20 years, laparoscopic liver surgery has had an important development in specialized centers.

OBJECTIVE

To describe the initial experience in laparoscopic liver resection for benign and malignant tumors, to assess its indications and outcomes, and to describe technical aspects of these resections.

METHODS

Review of the records of 28 patients who underwent laparoscopic liver resection between November 2000 and November 2007. Analysis of the data regarding preoperative management and postoperative outcomes.

RESULTS

Twenty-six liver resections were performed laparoscopically (20 purely laparoscopic, 3 hand assisted, and 3 hybrid technique) and 2 were converted to open surgery. The laparoscopic approach was attempted in 6% (28 out of 459) of the liver resections carried out in the analyzed period. Indications for resection were: benign tumors in 22 patients (78%) and malignant tumors in 6 patients (22%). Resections were minor in 27 patients (96%) and major in 1 patient (4%). Pringle maneuver was performed in 14 patients (50%). Margins were negative in all the cases. Mean operative time was 170 minutes (range 70 to 350), and the mean length of stay was 3 days (range 1 to 6). Mortality rate was 0%. Only 2 patients (7%) had postoperative minor complications (self-limited bile leaks).

CONCLUSIONS

In selected patients with benign and malignant liver tumors, laparoscopic liver resections can be safely performed. This procedure must be carried out by the surgeons trained in both the hepatobiliary and laparoscopic surgery.

Adenoma or atypical hepatic focal nodular hyperplasia: role of preoperative imaging and laparoscopic treatment

Differentiation of focal nodular hyperplasia (FNH) and other hypervascular liver lesions, such as hepatocellular adenoma (HCA), is important because of the drastically different therapeutic approach. However, FNH can be well distinguished only if it shows a typical aspect; alternatively, in the case of atypical FNH, imaging findings are not specific enough to provide a secure diagnosis and histologic verification of the lesion is required. In addition, HCA cannot be identified conclusively by any current available imaging technique and it can be at best suspected strongly, and this suspicion may lead to liver resection. Herein we report a case of a patient with an unusual FNH nodule presenting at ultrasonographic scanning as an isoechoic mass arising from hepatic segment 4b; the diagnostic indecision between FNH and HCA was not definitively solved even after computed tomography scan and magnetic resonance imaging and the patient was scheduled for a laparoscopic resection. The pathologic examination diagnosed an atypical FNH nodule. The clinical doubt between FNH and HCA remains a problem affecting the clinicians, and more effort should be made in the direction of a better preoperative differentiation of such different conditions. Surgical resection should not be considered as the failure of the preoperative diagnostic attempt, but as the mainstay for a definitive and sure diagnosis.

Laparoscopic liver surgery

Great advances have occurred in the field of laparoscopic hepatic surgery. It is now clear that in experienced hands, the laparoscopic method of liver resection is as safe as an open procedure. The key phrase in this last sentence is "in experienced hands". The new devices that are available might make an inexperienced hepatic surgeon, well-trained in laparoscopic surgery, embark on hepatic resection without thorough knowledge of hepatic anatomy. The converse may also be true. As no criteria for credentialing of laparoscopic hepatic surgeons exist, the decision as to who is sufficiently trained to perform these procedures is left to individual hospital credentialing boards. While a certification procedure defined by leaders in this field and supported by surgical societies would be welcomed, the ability to achieve and enforce these guidelines appear to be more of a challenge. In addition, while most comparison studies in this area conclude by suggesting that a randomized, clinical trial would be needed to definitively arrive at an answer regarding the benefits of minimally invasive liver surgery compared with open surgery, it would likely be extremely difficult to accrue patients, given the data presented in articles regarding the success of laparoscopic hepatic resections. The authors conclude that an internationalregistry of all laparoscopic cases should b e established to insure patient safety and a mechanism for self-monitoring.

Ressecões hepáticas por videolaparoscopia

INTRODUÇÃO: As ressecções hepáticas representam umas das últimas fronteiras vencidas pela cirurgia videolaparoscópica. Apesar da complexidade do procedimento, da demanda de grande incorporação de tecnologia e necessidade de experiência em cirurgia hepática e laparoscópica, a indicação do método tem crescido de forma expressiva nos últimos anos. OBJETIVO: Realizar análise crítica do método, baseada nos trabalhos existentes na literatura, ressaltando o estado atual de suas indicações, exequibilidade, segurança, resultados e aspectos técnicos primordiais. MÉTODO: Foram identificados e analisados os trabalhos pertinentes nas bases de dados LILACS e PUBMED até dezembro de 2009, utilizando-se os descritores "liver resection", "laparoscopic" e "liver surgery". Não foram encontrados trabalhos prospectivos e randomizados sobre o tema, sendo os dados disponíveis provenientes de série de casos, estudos caso-controle e alguns estudos multicêntricos e metanálises. CONCLUSÃO: A hepatectomia por videolaparoscopia é hoje operação segura e factível, mesmo para as ressecções hepáticas maiores, com baixo índice de morbimortalidade. O método pode ser utilizado para lesões malignas sem prejuízo dos princípios oncológicos e com vantagens nos pacientes com cirrose ou disfunção hepática. A melhor indicação recai sobre as lesões benignas, em especial o adenoma hepatocelular. Em mãos experientes e casos selecionados, como as lesões benignas localizadas nos segmentos anterolaterais hepáticos, principalmente no segmento lateral esquerdo, a ressecção videolaparoscópica pode ser considerada hoje como tratamento padrão.

Experience with more than 500 minimally invasive hepatic procedures

OBJECTIVE

To evaluate our experience with more than 500 minimally invasive hepatic procedures.

SUMMARY BACKGROUND DATA

Recent data have confirmed the safety and efficacy of minimally invasive liver surgery. Despite these reports, no programmatic approach to minimally invasive liver surgery has been proposed.

METHODS

We retrospectively reviewed all patients who underwent a minimally invasive procedure for the management of hepatic tumors between January 2001 and April 2008. Patients were divided into 3 groups: laparoscopy with intraoperative ultrasound and biopsy only, laparoscopic radiofrequency ablation (RFA), and minimally invasive resection. To compare the various forms of surgery, we analyzed the incidence of complications, tumor recurrence, mortality, and cost. Statistical analysis was performed using chi(2) analysis, Student t test, Kaplan-Meier survival analysis with the log-rank test, and multivariable Cox models.

RESULTS

A total of 590 minimally invasive hepatic procedures were performed during 489 operative interventions. The representative tumor histologies were: hepatocellular carcinoma (HCC; N = 210), colorectal carcinoma (N = 40), miscellaneous liver metastases (N = 42), biliary cancer (N = 20), and benign tumors (N = 176). Thirty-five patients underwent laparoscopic ultrasound and confirmatory biopsy alone; 201 patients underwent 240 laparoscopic RFAs, and 253 patients underwent 306 minimally invasive resections. Conversion rates to open surgery for the RFA and resection group were 2% overall. One hundred ninety-nine (40.6%) patients were cirrhotic; 31 resections were performed in cirrhotic patients. Complication and mortality rates for RFA and resection were comparable (11% vs. 16%, and 1.5% vs. 1.6%). However, complication rates (14% vs. 29%; P = 0.02) and mortality (0.3% vs. 9.7%; P = 0.006) rates were higher in the cirrhotic versus noncirrhotic resection group. Overall recurrence rates for RFA and resection groups were 24% and 23%, respectively. Local recurrence rates were higher in the RFA group (6.3% versus 1.5%; P < 0.06). Overall patient survival differed between HCC patients receiving RFA alone and those receiving RFA and OLT (P < 0.0001). Overall survival for cancer patients receiving RFA versus resection differed significantly when unadjusted for other covariates (P = 0.01), and remained marginally significant in a multivariable model (P = 0.056).

CONCLUSIONS

Minimally invasive hepatic surgery has become a viable alternative to open hepatic surgery. Our present data are equivalent or superior to those encountered in any large open series. Our experience with RFA confirms a low local recurrence rate and an excellent technique for bridging patients to transplantation. Morbidity and mortality rates for minimally invasive hepatic resections in cirrhotics, is similar to other reported open resection series. This series confirmed excellent interim survival rates after laparoscopic HR and superiority over RFA in the treatment of cancer, with significantly lower local tumor recurrence rate.

Laparoscopic treatment of biliary hepatic cysts: short- and medium-term results

BACKGROUND

The aim of this study was to evaluate the postoperative morbidity and, in the medium-term results, the incidence of relapses in the laparoscopic treatment of non-parasitic hepatic cysts (NPHC) and polycystic liver disease (PCLD).

PATIENTS AND METHODS

From 1999 to 2003, 12 patients with NPHC and 3 patients with PCLD with few large cysts in the anterior hepatic segments underwent laparoscopic fenestration and deroofing.

RESULTS

There were no conversions and no mortality; the mean operative time was 55 min for NPHC and 120 min for PCLD. Postoperative morbidity comprised two patients with bronchopneumonic infiltrations and in one patient with PCLD ascites resolved spontaneously. All the patients experienced resolution of the symptomatology. Follow-up was carried out from 3 to 38 months (mean 18 months). There was no relapse of the disease.

DISCUSSION

The preoperative selection of patients is fundamental to program the surgical treatment. Laparoscopy can be considered a safe and efficacious treatment for NPHC and PCLD.