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Aghayan DL, Kazaryan AM, Fretland ÅA, Røsok B, Barkhatov L, Lassen K, Edwin B. Evolution of laparoscopic liver surgery: 20-year experience of a Norwegian high-volume referral center. Surg Endosc 2021; 36:2818-2826. [PMID: 34036419 PMCID: PMC9001574 DOI: 10.1007/s00464-021-08570-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/18/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Laparoscopic liver surgery has evolved to become a standard surgical approach in many specialized centers worldwide. In this study we present the evolution of laparoscopic liver surgery at a single high-volume referral center since its introduction in 1998. METHODS Patients who underwent laparoscopic liver resection (LLR) between August 1998 and December 2018 at the Oslo University Hospital were analyzed. Perioperative outcomes were compared between three time periods: early (1998 to 2004), middle (2005 to 2012) and recent (2013-2018). RESULTS Up to December 2020, 1533 LLRs have been performed. A total of 1232 procedures were examined (early period, n = 62; middle period, n = 367 and recent period, n = 803). Colorectal liver metastasis was the main indication for surgery (68%). The rates of conversion to laparotomy and hand-assisted laparoscopy were 3.2% and 1.4%. The median operative time and blood loss were 130 min [interquartile range (IQR), 85-190] and 220 ml (IQR, 50-600), respectively. The total postoperative complications rate was 20.3% and the 30-day mortality was 0.3%. The median postoperative stay was two (IQR, 2-4) days. When comparing perioperative outcomes between the three time periods, shorter operation time (median, from 182 to 120 min, p < 0.001), less blood loss (median, from 550 to 200 ml, p = 0.023), decreased rate of conversions to laparotomy (from 8 to 3%) and shorter postoperative hospital stay (median, from 3 to 2 days, p < 0.001) was observed in the later periods, while the number of more complex liver resections had increased. CONCLUSION During the last two decades, the indications, the number of patients and the complexity of laparoscopic liver procedures have expanded significantly. Initially being an experimental approach, laparoscopic liver surgery is now safely implemented across our unit and has become the method of choice for surgical treatment of most liver tumors.
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Affiliation(s)
- Davit L Aghayan
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, 0027, Oslo, Norway.
- Department of Surgery N1, Yerevan State Medical University After M. Heratsi, Yerevan, Armenia.
| | - Airazat M Kazaryan
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, 0027, Oslo, Norway
- Department of Surgery N1, Yerevan State Medical University After M. Heratsi, Yerevan, Armenia
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
- Department of Gastrointestinal Surgery, Østfold Hospital Trust, Grålum, Norway
- Department of Faculty Surgery, №2I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Åsmund Avdem Fretland
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, 0027, Oslo, Norway
- Department of HPB Surgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Bård Røsok
- Department of HPB Surgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Leonid Barkhatov
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, 0027, Oslo, Norway
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
- Department of Gastrointestinal Surgery, Haukeland University Hospital, Bergen, Norway
| | - Kristoffer Lassen
- Department of HPB Surgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Bjørn Edwin
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, 0027, Oslo, Norway
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
- Department of HPB Surgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway
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2
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Aghayan DL, Kazaryan AM, Dagenborg VJ, Røsok BI, Fagerland MW, Waaler Bjørnelv GM, Kristiansen R, Flatmark K, Fretland ÅA, Edwin B. Long-Term Oncologic Outcomes After Laparoscopic Versus Open Resection for Colorectal Liver Metastases : A Randomized Trial. Ann Intern Med 2021; 174:175-182. [PMID: 33197213 DOI: 10.7326/m20-4011] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Despite the recent worldwide dissemination of laparoscopic liver surgery, no high-level evidence supports the oncologic safety of this approach. OBJECTIVE To evaluate long-term oncologic outcomes after laparoscopic versus open liver resection in patients with colorectal metastases. DESIGN A single-center, assessor-blinded, randomized controlled trial (OSLO-COMET [Oslo Randomized Laparoscopic Versus Open Liver Resection for Colorectal Metastases Trial]). (ClinicalTrials.gov: NCT01516710). SETTING Oslo University Hospital, the only provider of liver surgery for the 3 million inhabitants of southeastern Norway. PARTICIPANTS Patients with resectable colorectal liver metastases were randomly assigned to have open or laparoscopic liver resection. INTERVENTION From February 2012 to January 2016, a total of 280 patients were included in the trial (laparoscopic surgery: n = 133; open surgery: n = 147). MEASUREMENTS The primary outcome was postoperative morbidity within 30 days. Five-year rates of overall and recurrence-free survival were predefined secondary end points. RESULTS At a median follow-up of 70 months, rates of 5-year overall survival were 54% in the laparoscopic group and 55% in the open group (between-group difference, 0.5 percentage point [95% CI, -11.3 to 12.3 percentage points]; hazard ratio, 0.93 [CI, 0.67 to 1.30]; P = 0.67). Rates of 5-year recurrence-free survival were 30% in the laparoscopic group and 36% in the open group (between-group difference, 6.0 percentage points [CI, -6.7 to 18.7 percentage points]; hazard ratio, 1.09 [CI, 0.80 to 1.49]; P = 0.57). LIMITATION The trial was not powered to detect differences in secondary end points and was not designed to address a noninferiority hypothesis for survival outcomes. CONCLUSION In this randomized trial of laparoscopic and open liver surgery, no difference in survival outcomes was found between the treatment groups. However, differences in 5-year overall survival up to about 10 percentage points in either direction cannot be excluded. This trial should be followed by pragmatic multicenter trials and international registries. PRIMARY FUNDING SOURCE The South-Eastern Norway Regional Health Authority.
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Affiliation(s)
- Davit L Aghayan
- The Intervention Centre at Oslo University Hospital and Institute of Clinical Medicine at University of Oslo, Oslo, Norway, and Yerevan State Medical University after Mkhitar Heratsi, Yerevan, Armenia (D.L.A.)
| | - Airazat M Kazaryan
- The Intervention Centre at Oslo University Hospital, Oslo, and Østfold Hospital Trust, Grålum, Norway, Yerevan State Medical University after Mkhitar Heratsi, Yerevan, Armenia, and I.M. Sechenov First Moscow State Medical University, Moscow, Russia (A.M.K.)
| | - Vegar Johansen Dagenborg
- Institute of Clinical Medicine at University of Oslo and Oslo University Hospital, Oslo, Norway (V.J.D., K.F.)
| | - Bård I Røsok
- Oslo University Hospital Rikshospitalet, Oslo, Norway (B.I.R.)
| | - Morten Wang Fagerland
- Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway (M.W.F.)
| | | | - Ronny Kristiansen
- The Intervention Centre at Oslo University Hospital, Oslo, Norway (R.K., Å.A.F.)
| | - Kjersti Flatmark
- Institute of Clinical Medicine at University of Oslo and Oslo University Hospital, Oslo, Norway (V.J.D., K.F.)
| | | | - Bjørn Edwin
- The Intervention Centre at Oslo University Hospital and Institute of Clinical Medicine at University of Oslo, Oslo, Norway (B.E.)
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3
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Aghayan DL, Kalinowski P, Kazaryan AM, Fretland ÅA, Sahakyan MA, Røsok BI, Pelanis E, Bjørnbeth BA, Edwin B. Laparoscopic liver resection for non-colorectal non-neuroendocrine metastases: perioperative and oncologic outcomes. World J Surg Oncol 2019; 17:156. [PMID: 31484583 PMCID: PMC6727573 DOI: 10.1186/s12957-019-1700-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 08/28/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Liver resection is a treatment of choice for colorectal and neuroendocrine liver metastases, and laparoscopy is an accepted approach for surgical treatment of these patients. The role of liver resection for patients with non-colorectal non-neuroendocrine liver metastases (NCNNLM), however, is still disputable. Outcomes of laparoscopic liver resection for this group of patients have not been analyzed. MATERIAL AND METHODS In this retrospective study, patients who underwent laparoscopic liver resection for NCNNLM at Oslo University Hospital between April 2000 and January 2018 were analyzed. Perioperative and oncologic data of these patients were examined. Postoperative morbidity was classified using the Accordion classification. Kaplan-Meier method was used for survival analysis. Median follow-up was 26 (IQR, 12-41) months. RESULTS Fifty-one patients were identified from a prospectively collected database. The histology of primary tumors was classified as adenocarcinoma (n = 16), sarcoma (n = 4), squamous cell carcinoma (n = 4), melanoma (n = 16), gastrointestinal stromal tumor (n = 9), and adrenocortical carcinoma (n = 2). The median operative time was 147 (IQR, 95-225) min, while the median blood loss was 200 (IQR, 50-500) ml. Nine (18%) patients experienced postoperative complications. There was no 90-day mortality in this study. Thirty-five (68%) patients developed disease recurrence or progression. Seven (14%) patients underwent repeat surgical procedure for recurrent liver metastases. One-, three-, and five-year overall survival rates were 85%, 52%, and 38%, respectively. The median overall survival was 37 (95%CI, 25 to 49) months. CONCLUSION Laparoscopic liver resection for NCNNLM results in good outcomes and should be considered in patients selected for surgical treatment.
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Affiliation(s)
- Davit L Aghayan
- The Intervention Centre, Oslo University Hospital-Rikshospitalet, Pb. 4950 Nydalen, 0424, Oslo, Norway. .,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway. .,Department of Surgery N1, Yerevan State Medical University after M. Heratsi, Yerevan, Armenia.
| | - Piotr Kalinowski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Airazat M Kazaryan
- The Intervention Centre, Oslo University Hospital-Rikshospitalet, Pb. 4950 Nydalen, 0424, Oslo, Norway.,Department of Surgery N1, Yerevan State Medical University after M. Heratsi, Yerevan, Armenia.,Department of Surgery, Fonna Hospital Trust, Stord, Norway.,Department of Faculty Surgery N2, I.M.Sechenov First Moscow State Medical University, Moscow, Russia
| | - Åsmund Avdem Fretland
- The Intervention Centre, Oslo University Hospital-Rikshospitalet, Pb. 4950 Nydalen, 0424, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Mushegh A Sahakyan
- The Intervention Centre, Oslo University Hospital-Rikshospitalet, Pb. 4950 Nydalen, 0424, Oslo, Norway.,Department of Surgery N1, Yerevan State Medical University after M. Heratsi, Yerevan, Armenia.,Department of General and Laparoscopic Surgery, Central Clinical Military Hospital, Yerevan, Armenia
| | - Bård I Røsok
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Egidijus Pelanis
- The Intervention Centre, Oslo University Hospital-Rikshospitalet, Pb. 4950 Nydalen, 0424, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Bjørn Atle Bjørnbeth
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Bjørn Edwin
- The Intervention Centre, Oslo University Hospital-Rikshospitalet, Pb. 4950 Nydalen, 0424, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
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4
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Laparoscopic Multiple Parenchyma-sparing Concomitant Liver Resections for Colorectal Liver Metastases. Surg Laparosc Endosc Percutan Tech 2019; 29:187-193. [DOI: 10.1097/sle.0000000000000606] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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5
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van der Poel MJ, Barkhatov L, Fuks D, Berardi G, Cipriani F, Aljaiuossi A, Lainas P, Dagher I, D'Hondt M, Rotellar F, Besselink MG, Aldrighetti L, Troisi RI, Gayet B, Edwin B, Abu Hilal M. Multicentre propensity score-matched study of laparoscopic versus open repeat liver resection for colorectal liver metastases. Br J Surg 2019; 106:783-789. [PMID: 30706451 DOI: 10.1002/bjs.11096] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 10/11/2018] [Accepted: 11/27/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Repeat liver resection is often the best treatment option for patients with recurrent colorectal liver metastases (CRLM). Repeat resections can be complex, however, owing to adhesions and altered liver anatomy. It remains uncertain whether the advantages of a laparoscopic approach are upheld in this setting. The aim of this retrospective, propensity score-matched study was to compare the short-term outcome of laparoscopic (LRLR) and open (ORLR) repeat liver resection. METHODS A multicentre retrospective propensity score-matched study was performed including all patients who underwent LRLRs and ORLRs for CRLM performed in nine high-volume centres from seven European countries between 2000 and 2016. Patients were matched based on propensity scores in a 1 : 1 ratio. Propensity scores were calculated based on 12 preoperative variables, including the approach to, and extent of, the previous liver resection. Operative outcomes were compared using paired tests. RESULTS Overall, 425 repeat liver resections were included. Of 271 LRLRs, 105 were matched with an ORLR. Baseline characteristics were comparable after matching. LRLR was associated with a shorter duration of operation (median 200 (i.q.r. 123-273) versus 256 (199-320) min; P < 0·001), less intraoperative blood loss (200 (50-450) versus 300 (100-600) ml; P = 0·077) and a shorter postoperative hospital stay (5 (3-8) versus 6 (5-8) days; P = 0·028). Postoperative morbidity and mortality rates were similar after LRLR and ORLR. CONCLUSION LRLR for CRLM is feasible in selected patients and may offer advantages over an open approach.
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Affiliation(s)
- M J van der Poel
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - L Barkhatov
- Interventional Centre and Department of Hepatopancreatobiliary Surgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - D Fuks
- Department of Digestive Disease, Institut Mutualiste Montsouris, Université Paris Descartes, Paris, France
| | - G Berardi
- Department of General and Hepatobiliary Surgery, Ghent University Hospital, Ghent, Belgium
| | - F Cipriani
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - A Aljaiuossi
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - P Lainas
- Department of Surgery, Antoine Béclère Hospital, Paris, France
| | - I Dagher
- Department of Surgery, Antoine Béclère Hospital, Paris, France
| | - M D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - F Rotellar
- Department of General and Abdominal Surgery, Clinica Universidad de Navarra, Pamplona, Spain
| | - M G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - L Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy
| | - R I Troisi
- Department of General and Hepatobiliary Surgery, Ghent University Hospital, Ghent, Belgium
| | - B Gayet
- Department of Digestive Disease, Institut Mutualiste Montsouris, Université Paris Descartes, Paris, France
| | - B Edwin
- Interventional Centre and Department of Hepatopancreatobiliary Surgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - M Abu Hilal
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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6
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Laparoscopic Versus Open Resection for Colorectal Liver Metastases: The OSLO-COMET Randomized Controlled Trial. Ann Surg 2019; 267:199-207. [PMID: 28657937 DOI: 10.1097/sla.0000000000002353] [Citation(s) in RCA: 425] [Impact Index Per Article: 85.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To perform the first randomized controlled trial to compare laparoscopic and open liver resection. SUMMARY BACKGROUND DATA Laparoscopic liver resection is increasingly used for the surgical treatment of liver tumors. However, high-level evidence to conclude that laparoscopic liver resection is superior to open liver resection is lacking. METHODS Explanatory, assessor-blinded, single center, randomized superiority trial recruiting patients from Oslo University Hospital, Oslo, Norway from February 2012 to January 2016. A total of 280 patients with resectable liver metastases from colorectal cancer were randomly assigned to undergo laparoscopic (n = 133) or open (n = 147) parenchyma-sparing liver resection. The primary outcome was postoperative complications within 30 days (Accordion grade 2 or higher). Secondary outcomes included cost-effectiveness, postoperative hospital stay, blood loss, operation time, and resection margins. RESULTS The postoperative complication rate was 19% in the laparoscopic-surgery group and 31% in the open-surgery group (12 percentage points difference [95% confidence interval 1.67-21.8; P = 0.021]). The postoperative hospital stay was shorter for laparoscopic surgery (53 vs 96 hours, P < 0.001), whereas there were no differences in blood loss, operation time, and resection margins. Mortality at 90 days did not differ significantly from the laparoscopic group (0 patients) to the open group (1 patient). In a 4-month perspective, the costs were equal, whereas patients in the laparoscopic-surgery group gained 0.011 quality-adjusted life years compared to patients in the open-surgery group (P = 0.001). CONCLUSIONS In patients undergoing parenchyma-sparing liver resection for colorectal metastases, laparoscopic surgery was associated with significantly less postoperative complications compared to open surgery. Laparoscopic resection was cost-effective compared to open resection with a 67% probability. The rate of free resection margins was the same in both groups. Our results support the continued implementation of laparoscopic liver resection.
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7
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Aghayan DL, Pelanis E, Avdem Fretland Å, Kazaryan AM, Sahakyan MA, Røsok BI, Barkhatov L, Bjørnbeth BA, Jakob Elle O, Edwin B. Laparoscopic Parenchyma-sparing Liver Resection for Colorectal Metastases. Radiol Oncol 2017. [PMID: 29520204 PMCID: PMC5839080 DOI: 10.1515/raon-2017-0046] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Laparoscopic liver resection (LLR) of colorectal liver metastases (CLM) is increasingly performed in specialized centers. While there is a trend towards a parenchyma-sparing strategy in multimodal treatment for CLM, its role is yet unclear. In this study we present short- and long-term outcomes of laparoscopic parenchyma-sparing liver resection (LPSLR) at a single center. Patients and methods LLR were performed in 951 procedures between August 1998 and March 2017 at Oslo University Hospital, Oslo, Norway. Patients who primarily underwent LPSLR for CLM were included in the study. LPSLR was defined as non-anatomic hence the patients who underwent hemihepatectomy and sectionectomy were excluded. Perioperative and oncologic outcomes were analyzed. The Accordion classification was used to grade postoperative complications. The median follow-up was 40 months. Results 296 patients underwent primary LPSLR for CLM. A single specimen was resected in 204 cases, multiple resections were performed in 92 cases. 5 laparoscopic operations were converted to open. The median operative time was 134 minutes, blood loss was 200 ml and hospital stay was 3 days. There was no 90-day mortality in this study. The postoperative complication rate was 14.5%. 189 patients developed disease recurrence. Recurrence in the liver occurred in 146 patients (49%), of whom 85 patients underwent repeated surgical treatment (liver resection [n = 69], ablation [n = 14] and liver transplantation [n = 2]). Five-year overall survival was 48%, median overall survival was 56 months. Conclusions LPSLR of CLM can be performed safely with the good surgical and oncological results. The technique facilitates repeated surgical treatment, which may improve survival for patients with CLM.
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Affiliation(s)
- Davit L Aghayan
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, Pb. 4950 Nydalen, 0424, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Egidijus Pelanis
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, Pb. 4950 Nydalen, 0424, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Åsmund Avdem Fretland
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, Pb. 4950 Nydalen, 0424, Oslo, Norway.,Department of HPB Surgery, Oslo University Hospital - Rikshospitalet, Rikshospitalet, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Airazat M Kazaryan
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, Pb. 4950 Nydalen, 0424, Oslo, Norway.,Department of Gastrointestinal Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Mushegh A Sahakyan
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, Pb. 4950 Nydalen, 0424, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Bård I Røsok
- Department of HPB Surgery, Oslo University Hospital - Rikshospitalet, Rikshospitalet, Norway
| | - Leonid Barkhatov
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, Pb. 4950 Nydalen, 0424, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Bjørn Atle Bjørnbeth
- Department of HPB Surgery, Oslo University Hospital - Rikshospitalet, Rikshospitalet, Norway
| | - Ole Jakob Elle
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, Pb. 4950 Nydalen, 0424, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Bjørn Edwin
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, Pb. 4950 Nydalen, 0424, Oslo, Norway.,Department of HPB Surgery, Oslo University Hospital - Rikshospitalet, Rikshospitalet, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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8
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Aghayan DL, Kazaryan AM, Fretland ÅA, Sahakyan MA, Røsok BI, Bjørnbeth BA, Edwin B. Laparoscopic liver resection for metastatic melanoma. Surg Endosc 2017; 32:1470-1477. [PMID: 28916919 DOI: 10.1007/s00464-017-5834-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 08/20/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Stage IV metastatic melanoma carries a poor prognosis. In the case of melanoma liver metastasis (MLM), surgical resection may improve survival and represents a therapeutic option, with varying levels of success. Laparoscopic liver resection (LLR) for metastatic melanoma is poorly studied. The aim of this study was to analyze the outcomes of LLR in patients with MLM. MATERIALS AND METHODS Between April 2000 and August 2013, 11 (1 cutaneous, 9 ocular and 1 unknown primary) patients underwent LLR for MLM at Oslo University Hospital-Rikshospitalet and 13 procedures in total were carried out. Perioperative and oncologic outcomes were analyzed. Postoperative morbidity was classified using the Accordion classification. Kaplan-Meier method was used for survival analysis. RESULTS A total of 23 liver specimens were resected. The median operative time was 137 (65-470) min, while the median blood loss was less than 50 (<50-900) ml. No intraoperative unfavorable incidents and 30-day mortality occurred. Median follow-up was 33 (9-92) months. Ten patients (91%) developed recurrence within a median of 5 months (2-18 months) and two patients underwent repeat LLR for recurrent liver metastases. One-, three-, and five-year overall survival rates were 82, 45 and 9%, respectively. The median overall survival was 30 (9-92) months. CONCLUSION Perioperative morbidity and long-term survival after LLR for MLM seems to be comparable to open liver resection. Thus, LLR may be preferred over open liver resection due to the well-known advantages of laparoscopy, such as reduced pain and improved possibility for repeated resections.
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Affiliation(s)
- Davit L Aghayan
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, Pb. 4950 Nydalen, 0424, Oslo, Norway.
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Airazat M Kazaryan
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, Pb. 4950 Nydalen, 0424, Oslo, Norway
- Department of Gastrointestinal Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Åsmund Avdem Fretland
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, Pb. 4950 Nydalen, 0424, Oslo, Norway
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Mushegh A Sahakyan
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, Pb. 4950 Nydalen, 0424, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Bård I Røsok
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Bjørn Atle Bjørnbeth
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Bjørn Edwin
- The Intervention Centre, Oslo University Hospital - Rikshospitalet, Pb. 4950 Nydalen, 0424, Oslo, Norway
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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9
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Mala T, Aurdal L, Frich L, Samset E, Hol PK, Edwin B, Søreide O, Gladhaug I. Liver Tumor Cryoablation: A Commentary on the Need of Improved Procedural Monitoring. Technol Cancer Res Treat 2016; 3:85-91. [PMID: 14750897 DOI: 10.1177/153303460400300110] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Cryoablation is a method used for in situ destruction of liver tumors not eligible for surgical resection. Local recurrences following such treatment have been reported at rates of 5–44%. Insufficient procedural monitoring of the ablation is one plausible explanation for these recurrences. The cryoablative procedure is usually monitored by ultrasonography, but acoustic shadowing and loss of signals, compromise visualisation of the cryolesion circumference. Other monitoring modalities such as computer tomography and invasive methods like the use of thermocouples and impedance measurements have also been studied, but are not in common clinical use as single monitoring modalities. Thermodynamic conditions assumed adequate for tumor eradication are likely to occur only in parts of the cryolesion. This tumoricidal part of the cryolesion is not adequately depicted using any of these modalities. Magnetic resonance imaging (MRI) provides a clear delineation of the cryolesion circumference. Noninvasive temperature measurements assisted by MRI indicate which parts of the cryolesion that may be subject to complete necrosis. In this article MRI monitored cryoablation of liver tumors is discussed. Improved peroperative monitoring as offered by MRI may reduce the rates of local recurrences after treatment, but further technological improvements are required.
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Affiliation(s)
- Tom Mala
- Interventional Centre, Rikshospitalet, Oslo, Norway.
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10
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Boggi U, Caniglia F, Vistoli F, Costa F, Pieroni E, Perrone VG. Laparoscopic robot-assisted resection of tumors located in posterosuperior liver segments. Updates Surg 2015; 67:177-83. [PMID: 26076915 DOI: 10.1007/s13304-015-0304-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 05/25/2015] [Indexed: 02/07/2023]
Abstract
Laparoscopic resection of liver tumors located in the posterosuperior segments is a challenging operation that could be facilitated by robotic assistance. Laparoscopic resection of 12 tumors located in posterosuperior segments (IVa: 1; VII: 5; VIII: 6) was carried out under robotic assistance. All patients had a single tumor nodule. Data were collected prospectively and analyzed retrospectively. Surgery required a mean of 260.4 min (115-430) and was completed laparoscopically in all but one patient, who required conversion to mini-laparotomy because of intolerance of pneumoperitoneum (8.3%). Mean estimated blood loss was 252.7 ml (50-600), making transfusion necessary in 3 patients (25.0%). Post-operative complications occurred in 4 patients (33.3%), being of Clavien-Dindo grade II in 3 patients (25.0%) and Clavien-Dindo grade IV in 1 patient (8.3%). Reoperation was required in 1 patient, who subsequently had a long hospital stay, because of decompensated cirrhosis. Median length of hospital stay was 8.5 days (7-96). No patient was readmitted. Pathology showed hepatocellular carcinoma in 7 patients (58.3%), liver metastasis in 2 patients (16.6%), and hepatic adenoma, focal nodular hyperplasia, and hemangioma in one patient each (8.3%). All patients had a margin negative resection. After a mean follow-up period of 21.4 months (±24.4), no patient with malignant histology developed recurrence. Our initial experience confirms that laparoscopic robot-assisted resection of tumors located in the posterosuperior segments is feasible. Further experience is needed before final conclusions can be drawn and meaningful comparison with other surgical techniques becomes possible.
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Affiliation(s)
- Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy,
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Kazaryan AM, Røsok BI, Marangos IP, Rosseland AR, Edwin B. Comparative evaluation of laparoscopic liver resection for posterosuperior and anterolateral segments. Surg Endosc 2011; 25:3881-9. [PMID: 21735326 PMCID: PMC3213339 DOI: 10.1007/s00464-011-1815-x] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Accepted: 06/09/2011] [Indexed: 02/06/2023]
Abstract
Background Totally laparoscopic liver resection of lesions located in the posterosuperior segments is reported to be technically challenging. This study aimed to define whether these technical difficulties affect the surgical outcome. Methods A total of 220 patients underwent laparoscopic liver resection during 244 procedures from August 1998 to December 2010. The patients who underwent primary minor single liver resection for malignant tumors affecting either posterosuperior segments 1, 7, 8, and, 4a (group 1) or anterolateral segments 2, 3, 5, 6, and 4b (group 2) were included in the study. Seventy-five procedures found to be eligible for the study, including 28 patients in group 1 and 47 patients in group 2. Intraoperative unfavorable incidents were graded on the basis of the Satava approach and postoperative complications were graded in agreement with the Accordion classification. Results The operative time (median, 127 min) and blood loss (median, 200 ml) were equivalent in the two groups. The rates for blood transfusions and intraoperative accidents did not differ statistically between the groups. A tumor-free margin resection was achieved in 94.7% of the procedures, equivalently in both groups. The postoperative course was similar in the two groups. Postoperative complications developed in 2 cases (7.1%) in group 1 and 2 cases (4.3%) in group 2 (p = 0.626). The median hospital stay was 2 days in both groups. Conclusions Laparoscopic liver resection for lesions located in posterosuperior segments represents certain technical challenges. However, appropriate adjustment of surgical techniques and optimal patient positioning enables the laparoscopic technique to provide safe and effective parenchyma-sparing resections for lesions located in both posterosuperior and anterolateral segments.
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Affiliation(s)
- Airazat M Kazaryan
- Interventional Centre, Rikshospitalet, Oslo University Hospital Health Trust, 0027 Oslo, Norway.
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Abstract
Laparoscopic liver resection (LHR) has shown classical advantages of minimally invasive surgery over open counterpart. In spite of introduction in early 1990's only few centres worldwide adapted LHR to routine practice. It was due to considerable technical challenges and uncertainty about oncologic outcomes. Surgical instrumentation and accumulation of surgical experience has largely enabled to solve many technical considerations. Intraoperative navigation options have also been improved. Consequently indications have been drastically expanded nearly reaching criteria equal to open liver resection in expert centres. Recent studies have verified oncologic integrity of LHR. However, mastering of LHR is still a quite demanding task limiting expansion of this patient friendly technique. This emphasizes the necessity of systematic training for laparoscopic liver surgery. This article reviews the state of the art of laparoscopic liver surgery lightening burning issues of research and clinical practice.
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Affiliation(s)
- B Edwin
- Intervention Centre, Oslo University Hospital, Rikshospitalet, Oslo, Norway.
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13
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Laparoscopic resection of colorectal liver metastases: surgical and long-term oncologic outcome. Ann Surg 2010; 252:1005-12. [PMID: 21107111 DOI: 10.1097/sla.0b013e3181f66954] [Citation(s) in RCA: 104] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To analyze the immediate and long-term outcome after laparoscopic resection of colorectal liver metastases and difference between observed and predicted [Fong's and Basingstoke Predictive Index (BPI) scores] survivals. BACKGROUND : Laparoscopic liver resection has been reported safe and feasible and improves postoperative course. The oncologic outcomes after resection of colorectal metastases are poorly reported. METHODS Between August 1998 and January 2010, 122 patients underwent laparoscopic resection for colorectal liver metastases during 135 procedures at Rikshospitalet. Patients undergoing surgery between August 1998 and June 2009 were included in research analysis. The patients had median Fong's and BPI's scores of 2 (0-5) and 7 (0-23), respectively. Mainstream analysis of hospital data was done on intent-to-treat basis. Intraoperative incidents and postoperative complications were analyzed according to the Satava and Clavien-Dindo classifications. Median follow-up was 24 (0-100) months. RESULTS One hundred fifty-one liver resections were performed in 107 patients during 118 procedures: 117 nonanatomic and 34 anatomic liver resections. There were 5 conversions to laparotomy (4.2%). The resection margin was free of tumor tissue in 141 (93.4%) of 151 specimens, and the distance between the resection margin and tumor tissue was median 6 (0-40) mm. Intraoperative incidents occurred in 14 cases (11.9%), including 5 (4.2%), 8 (6.8%), and 1 (0.8%) cases of grades I, II, and III, respectively. Postoperative complications were observed in 16 cases (14.3%), including 2, 3, 7, 3, 0, and 1 cases of grades I, II, IIIa, IIIb, IV, and V, respectively. During follow-up, 21 patients received repeat liver resection of recurrences (11 by laparoscopy and 10 by laparotomy). The 5-year overall survival rates were 51% as laparoscopically completed cases and 47% as intent-to-treat. The observed actuarial survival values exceeded the values expected by Fong's and BPI's score, with 10.2% and 6.7% as laparoscopically completed cases and with 3.8% and 2.4% as intent-to-treat, respectively. CONCLUSIONS Laparoscopic resection is a favorable alternative to open liver resection for patients with colorectal liver metastases. The observed actuarial survival values after laparoscopic resection surpass the values expected by major scoring systems.
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Laurence JM, Lam VWT, Langcake ME, Hollands MJ, Crawford MD, Pleass HCC. Laparoscopic hepatectomy, a systematic review. ANZ J Surg 2008; 77:948-53. [PMID: 17931255 DOI: 10.1111/j.1445-2197.2007.04288.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
This systematic review was undertaken to assess the published evidence for the safety, feasibility and reproducibility of laparoscopic liver resection. A computerized search of the Medline and Embase databases identified 28 non-duplicated studies including 703 patients in whom laparoscopic hepatectomy was attempted. Pooled data were examined for information on the patients, lesions, complications and outcome. The most common procedures were wedge resection (35.1%), segmentectomy (21.7%) and left lateral segmentectomy (20.9%). Formal right hepatectomy constituted less than 4% of the reported resections. The conversion and complication rates were 8.1% and 17.6%, respectively. The mortality rate over all these studies was 0.8% and the median (range) hospital stay 7.8 days (2-15.3 days). Eight case-control studies were analysed and although some identified significant reductions in-hospital stay, time to first ambulation after surgery and blood loss, none showed a reduction in complication or mortality rate for laparoscopically carried out resections. It is clear that certain types of laparoscopic resection are feasible and safe when carried out by appropriately skilled surgeons. Further work is needed to determine whether these conclusions can be generalized to include formal right hepatectomy.
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Affiliation(s)
- Jerome M Laurence
- Collaborative Transplant Research Group, University of Sydney, and Department of Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.
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Kokkalera U, Ghellai A, Vandermeer TJ. Laparoscopic hepatic caudate lobectomy. J Laparoendosc Adv Surg Tech A 2007; 17:36-8. [PMID: 17362176 DOI: 10.1089/lap.2006.05062] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Uthaiah Kokkalera
- Hepatopancreatobiliary Surgery, Guthrie Healthcare, Sayre, Pennsylvania 18840, USA
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Mala T. Cryoablation of liver tumours -- a review of mechanisms, techniques and clinical outcome. MINIM INVASIV THER 2006; 15:9-17. [PMID: 16687327 DOI: 10.1080/13645700500468268] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Several techniques exist for in situ destruction or ablation of liver tumours not eligible for resection. Cryoablation, i.e. the use of low temperatures to induce local tissue necrosis, was among the first of the thermal ablative techniques widely used. The procedures have typically been performed by surgeons during laparotomy, but recently minimally invasive cryoablation has been reported feasible. The present review focuses on mechanisms of tissue destruction, techniques of ablation including procedural monitoring, and clinical outcome following cryoablation of liver tumours. Plausible causes of tumour persistence at the site of ablation, i.e. local treatment failure, are discussed. Shortcomings exist in monitoring of the freezing process and may be a main cause. The evidence for the long-term outcome following liver tumour cryoablation needs to be improved. Cryoablation has been challenged by other techniques of tumour ablation such as radiofrequency ablation. Randomised trials against these modern techniques may define the role of cryoablation in the treatment of liver tumours. With improved imaging technology and patient selection, cryoablation of liver tumours may hold promise for selected patients.
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Affiliation(s)
- Tom Mala
- Surgical Department Aker University Hospital and Interventional Centre, Rikshospitalet, Oslo, Norway.
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Mala T, Edwin B, Rosseland AR, Gladhaug I, Fosse E, Mathisen O. Laparoscopic liver resection: experience of 53 procedures at a single center. ACTA ACUST UNITED AC 2006; 12:298-303. [PMID: 16133696 DOI: 10.1007/s00534-005-0974-3] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2004] [Accepted: 01/11/2005] [Indexed: 01/01/2023]
Abstract
BACKGROUND/PURPOSE The short-term outcome following laparoscopic liver resection at a single center is presented. METHODS Fifty-three procedures were carried out in 47 patients, between August 1998 and April 2004 (6 patients were resected on two occasions). A previous laparotomy and/or hepatectomy had been done in 83% and 26% of the procedures, respectively. Colorectal metastasis was the main indication for treatment (42/53). A total laparoscopic approach was applied. RESULTS Three of the 53 (6%) procedures were converted to laparotomy. In one additional procedure, radiofrequency ablation was done instead of resection. Sixty liver resections were done during the 49 procedures completed laparoscopically as planned (9 patients had concomitant resections performed). Nonanatomic (45/60) and anatomic (15/60; left lobectomies) resections were done. Tumor tissue was found in the resection margins of 6% of the specimens. The free margin was very short in 8% of the specimens. The morbidity was 16%. There was no mortality. Blood transfusions were given following 26% of the procedures. The median hospital stay was 3.5 days (range, 1-14 days) and the median number of days on which there was a need for opioids was 1 (range, 0-11 days). CONCLUSIONS Laparoscopic liver resection can be performed safely and seems to offer short-term benefits to the patients. Randomized studies are required to further evaluate the potential benefits of this treatment.
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Affiliation(s)
- Tom Mala
- Surgical Department, Rikshospitalet, 0027, Oslo, Norway
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Abstract
BACKGROUND The current experience of laparoscopic liver resection is reviewed focusing on the role and limitations of resection of colorectal metastases. Surgical technique, outcome, and the main controversies regarding the procedures are described. METHODS Current literature on laparoscopic liver resection is reviewed based on reports identified following a specified PubMed search. RESULTS Available evidence indicates that laparoscopic liver resection can be made safely in selected patients with comparable duration of surgery, blood loss, tumour clearance, and mortality to that of open resection. Tumours localised peripherally in the left lateral segments of the liver or in segments IV-VI seem to be best suited for laparoscopic resection. The laparoscopic approach may be beneficial to the patients as compared to conventional resection but randomised trials are pending. Laparoscopic resection of colorectal liver metastases is described in a small number of patients only. The long-term outcome following such resections is not adequately documented. CONCLUSIONS Laparoscopic liver resection is a promising technique with a comparable short-term outcome to that of open procedures but with the potential advantages of minimal invasive treatment. The technique should be further evaluated in properly designed trials. Laparoscopic resection of colorectal liver metastases should not be performed on a regular basis until long-term results are defined.
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Affiliation(s)
- Tom Mala
- Surgical Department, Aker University Hospital, Oslo, Norway.
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Abstract
The role of laparoscopic surgery in the management of benign cystic and solid liver tumours appears to differ according to each tumour type. As regards congenital liver cysts, laparoscopic treatment is now the gold standard for treating selected, huge, accessible, highly symptomatic or complicated cysts. In contrast, the laparoscopic approach is not useful for patients suffering from adult polycystic liver disease (PLD), except for type I PLD with large multiple hepatic cysts. For benign hepatocellular tumours, the surgical management has recently benefited from a better knowledge of the natural history of each type of tumour and from the improvement of imaging techniques in assuring a precise diagnosis of tumour nature. Thus the general tendency has led to a progressive restriction and tailoring of indications for resection in benign liver tumours, selecting only patients with huge, specifically symptomatic or compressive benign tumours or patients suffering from liver cell adenoma. Despite the enthusiastic use of the laparoscopic approach, selective indications for resection of benign liver tumours should indeed remain unchanged. For all types of benign liver tumours, the best indication remains small, superficial lesions, located in the anterior or the lateral segments of the liver. Deep, centrally located lesions or tumours in contact with major vascular or biliary trunks are not ideal candidates for laparoscopic liver resections. When performed by expert liver and laparoscopic surgeons using an adequate surgical technique, the laparoscopic approach is safe for performing minor liver resections and is accompanied by the usual postoperative benefits of laparoscopic surgery. When applied in selected patients and tumours, laparoscopic management of benign liver diseases appears to be a promising technique for hepatobiliary surgeons.
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Affiliation(s)
- Jean-François Gigot
- Unit of Hepato-Biliary-Pancreatic Surgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCL)BrusselsBelgium
| | - Catherine Hubert
- Unit of Hepato-Biliary-Pancreatic Surgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCL)BrusselsBelgium
| | - Radu Banice
- Unit of Hepato-Biliary-Pancreatic Surgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCL)BrusselsBelgium
| | - Michael L Kendrick
- Department of Gastroenterologic and General Surgery, Mayo Clinic and Mayo FoundationRochester MinnesotaUSA
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Cugat-Andorrà E, Isabel García-Domingo M, Bretcha-Boix P, Marco-Molina C, Rodríguez-Campos A. Laparoscopia y cirugía hepática: técnica e indicaciones. Cir Esp 2004. [DOI: 10.1016/s0009-739x(04)72268-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Although hepatic resection remains the treatment of choice for metastatic disease to the liver from colorectal cancer, the procedure is only possible for approximately 10% of patients. Ninety percent of patients with liver metastases ultimately die of liver failure. Thus, attention has turned to other, locoregional techniques that may be used alone or in conjunction with resection to increase the eligibility for some type of surgical, potentially curative treatment. One such option is cryotherapy. This review provides technical, physiologic, and outcome information regarding this technique. Semin Oncol 29:183-191.
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Affiliation(s)
- Tara K Sotsky
- Department of Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY 10467-2490, USA
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