Exploring the Role of Laparoscopic Surgery in Two-Stage Hepatectomy for Bilobar Colorectal Liver Metastases

Efficacy and perioperative safety of different future liver remnant modulation techniques: a systematic review and network meta-analysis

BACKGROUND

In daily clinical practice, different future liver remnant (FLR) modulation techniques are increasingly used to allow a liver resection in patients with insufficient FLR volume. This systematic review and network meta-analysis aims to compare the efficacy and perioperative safety of portal vein ligation (PVL), portal vein embolization (PVE), liver venous deprivation (LVD) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS).

METHODS

A literature search for studies comparing liver resections following different FLR modulation techniques was performed in MEDLINE, Embase and Cochrane Central, and pairwise and network meta-analyses were conducted.

RESULTS

Overall, 23 studies comprising 1557 patients were included. LVD achieved the greatest increase in FLR (17.32 %, 95% CI 2.49-32.15), while ALPPS was most effective in preventing dropout before the completion hepatectomy (OR 0.29, 95% CI 0.15-0.55). PVL tended to be associated with a longer time to completion hepatectomy (MD 5.78 days, 95% CI -0.67-12.23). Liver failure occurred less frequently after LVD, compared to PVE (OR 0.35, 95% CI 0.14-0.87) and ALPPS (OR 0.28, 95% CI 0.09-0.85).

DISCUSSION

ALPPS and LVD seem superior to PVE and PVL in terms of achieved FLR increase and subsequent treatment completion. LVD was associated with lower rates of post hepatectomy liver failure, compared to both PVE and ALPPS. A summary of the protocol has been prospectively registered in the PROSPERO database (CRD42022321474).

Safety and Feasibility of Laparoscopic Right or Extended Right Hemi Hepatectomy Following Modulation of the Future Liver Remnant in Patients with Colorectal Liver Metastases: A Systematic Review

Background: Major hepatectomies after future liver remnant (FLR) modulation are technically demanding procedures, especially when performed as minimally invasive surgery. The aim of this systematic review is to assess current evidence regarding the safety and feasibility of laparoscopic right or extended right hemihepatectomies after FLR modulation. Materials and Methods: The Medline, PubMed, Cochrane Library, and Embase databases were searched for studies involving laparoscopic right or extended right hemihepatectomies after FLR modulation, from their inception to December 2021. Two reviewers independently selected eligible articles and assessed their quality using the Newcastle-Ottawa Quality Assessment Scale (NOS). Baseline characteristics and outcomes were extracted from the included studies and summarized. Results: Six studies were included. In these studies, the median length of stay after the second stage ranged from 4.5 to 15.5 days and postoperative complication rates between 4.5% and 42.8%. Overall, 7.4% of patients developed liver failure, and 90-day mortality occurred in 3.2% of patients. The R0 resection rate was 93.5%. Only one study reported long-term outcomes, describing comparable 3-year overall survival rates following laparoscopic and open surgery (80% versus 54%, P = .154). Conclusions: The current evidence is scarce, but it suggests that in experienced centers, laparoscopic right or extended right hemihepatectomy, following FLR modulation, is a safe and feasible procedure.

Multiple Laparoscopic Liver Resection for Colorectal Liver Metastases

Over the past decades, liver cancer's minimally invasive approach has primarily become as a new standard of oncological care. Colorectal liver metastases (CRLM) are one of the most developed indications of laparoscopic liver resection (LLR). CRLM resection is still the best treatment known in terms of survival. As multiple CRLM are found in up to 80% of cases at diagnosis (Manfredi S. and al, Annals of Surgery 2006), a lot of possible technical management approaches are described. With the development of the parenchymal-sparing strategy, multiple concomitant laparoscopic liver resections (LLR) are gaining acceptance. However, no recommendation is available regarding its indications and feasibility. Also, laparoscopic two-stage hepatectomy is developing for bilobar CRLM, and this also does not have established recommendation. The purpose of this paper was to highlight novelty and updates in the field of multiple minimally invasive liver resections. A review of the international literature was performed. The feasibility of laparoscopic concomitant multiple LLR and two-stage hepatectomy for CRLM as well as their outcomes were discussed. These clarifications could further guide the implementation of minimal resection in multiple colorectal liver metastases therapies.

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.

The role of the laparoscopic approach in two-stage hepatectomy for colorectal liver metastases: a single-center experience

BACKGROUND

In selected patients, laparoscopic liver surgery for the treatment of colorectal liver metastases (CRLM) leads to better short-term outcomes and comparable oncologic outcomes in comparison with an open approach. However, its role in two-stage hepatectomy (TSH) remains poorly explored.

METHODS

A single-center retrospective study was performed to evaluate the role of laparoscopic liver resection (LLR) in the first and second stage of TSH. Demographic data, comorbid factors, perioperative outcomes, and short-term outcomes were evaluated.

RESULTS

Between September 2011 and May 2020, 23 patients were planned to undergo a TSH. The first stage hepatectomy (FSH) was performed laparoscopically in 22 patients (96%) without need for conversion. The median blood loss was 50 cc (IQR 30-100 cc) and postoperative length of hospital stay was 4 days (IQR 2.5-5 days). R0 resections were obtained in 18 FSHs (78%), while all others were R1 vascular (22%). Fourteen patients (61%) underwent a second stage hepatectomy (SSH). All SSHs were anatomically major hepatectomies. SSH was performed laparoscopically in 7 patients (50%), with need for conversion in 1 case (14%). The median blood loss was slightly lower in the open liver resection (OLR) group compared to the LLR group (200 cc (IQR 110-375 cc) vs. 240 cc (IQR 150-400 cc), respectively. The median postoperative length of hospital stay was 3 days shorter in the LLR group compared to the OLR group (4 days (IQR 3.5-4 days) vs. 7 days (IQR 4.5-8.5 days), respectively).

CONCLUSIONS

The already proven advantages of LLR in the treatment of CRLM favor the role of a laparoscopic approach in TSH for CRLM. In first stage minor or technically major hepatectomy, LLR is progressively becoming the gold standard. Laparoscopic second stage anatomically major hepatectomy is feasible in experienced hands, but should be limited to selected cases and should be performed in expert centers.

Current status of laparoscopic liver resection for the management of colorectal liver metastases

Colorectal cancer (CRC) is one of the most prevalent malignancies worldwide. The commonest site of spread is the liver, with up to 40% of patients developing colorectal liver metastasis (CLRM) during the course of their lifetime. Significant advances in surgical techniques, as well as breakthroughs in chemotherapy and biologic agents, have resulted in dramatic improvements in prognosis. A multimodal approach comprising of liver resection coupled with systemic therapy offers these patients the best chance of cure. The arrival of laparoscopic liver resection (LLR) within the last 3 decades has added a whole new dimension to the management of this condition. Today, CLRM is one of the most frequent indications for LLR globally. Meta-analyses of retrospective studies and two randomized trials have demonstrated superior short-term outcomes following LLR, with no differences in mortality rates. Oncologically, R0 resection rates are comparable to the open approach, while overall and disease-free survival rates are also similar. As surgeons gain confidence, boundaries are pushed even further. High-volume centers have published their early experiences with complex LLR of recurrent CLRM as well as totally laparoscopic synchronous resection of CRC and liver metastases, with very encouraging results. In the presence of extensive bilobar CLRM, two-stage hepatectomy (TSH) and associating liver partition with portal vein ligation (ALPPS) may be adopted to augment an inadequate future liver remnant to facilitate metastasectomy. Interestingly, the adoption of LLR for these techniques also seem to confer additional benefits. Despite the plethora of advantages, LLR comes with its own unique set of limitations such as a steep learning curve and high cost. The surgical world eagerly awaits the results of prospective trials currently underway in order to further advance the management of this disease.

Surgical technique and clinical results of one- or two-stage laparoscopic right hemihepatectomy after portal vein embolization in patients with initially unresectable colorectal liver metastases: A case series

BACKGROUND

The use of the laparoscopic approach in one-stage or second-step of two-stage right hemihepatectomy (RHH) after portal vein embolization (PVE) in patients with initially unresectable colorectal liver metastases (CRLMs) is technically demanding. Currently, there is limited published data regarding the technique and results required to better understand its safety and feasibility. This paper reports our experience, results, techniques and variety of tips and tricks (highlighted in the attached video), to facilitate this resection.

METHODS

A prospectively maintained database of laparoscopic liver surgery within our unit at a tertiary referral centre between August 2003 and March 2019 was reviewed. Patients with initially unresectable CRLMs who underwent laparoscopic RHH or extended RHH after PVE in the context of a one or two-stage procedure were included.

RESULTS

Between August 2003 and March 2019, 19 patients with initially unresectable CRLMs underwent laparoscopic RHH after PVE. Twelve patients (63.2%) had RHH in the context of a two-stage hepatectomy and 7 as a one-stage procedure. Median time interval between PVE and surgery was 42.5 days (IQR, 34.5-60.0 days). Mean operating time was 351.8 ± 80.5 minutes. Median blood loss was 850 mL (IQR, 475-1350 mL). Conversion to open surgery occurred in 2 of 19 cases (10.5%). Severe postoperative morbidity occurred in 2 patients. The mortality rate was 5.3%. Median postoperative hospital stay was 5 days (IQR, 4-7 days). Radical resection was obtained in eighteen patients (94.7%).

CONCLUSION

Laparoscopic RHH after PVE in the context of a one- or two-stage resection in patients with initially unresectable CRLMs is a safe and feasible procedure with favourable oncological outcomes.

Laparoscopic versus open two-stage hepatectomy for bilobar colorectal liver metastases: A bi-institutional, propensity score-matched study

BACKGROUND

The safety and feasibility of laparoscopic, two-stage hepatectomy for bilobar colorectal liver metastases is poorly evaluated.

METHODS

We reviewed retrospectively 86 consecutive patients who underwent complete two-stage hepatectomy (left lobe clearance as the first stage and standard/extended right hepatectomy as the second stage) for bilobar colorectal liver metastases between 2007 and 2017 in 2 tertiary centers. Short- and long-term outcomes were compared between laparoscopic and open two-stage hepatectomy before and after propensity score matching.

RESULTS

Laparoscopic two-stage hepatectomy was performed in 38 patients and open two-stage hepatectomy in 48. After propensity score matching, 25 laparoscopic and 25 open patients showed similar preoperative characteristics. For the first stage, a laparoscopic approach was associated with lesser hospital stays (4 vs 7.5 days; P < .001). For the second stage, a laparoscopic approach was associated with less blood loss (250 vs 500 mL; P = .040), less postoperative complications (32% vs 60%; P = .047), lesser hospital stays (9 vs 16 days; P = .013), and earlier administration of chemotherapy (1.6 vs 2 months; P = .039). Overall survival, recurrence-free survival, and liver-recurrence-free survival were comparable between the groups (3-year overall survival: 80% vs 54%; P = .154; 2-year recurrence-free survival: 20% vs 18%; P = .200; 2-year liver-recurrence-free survival: 39% vs 33%; P = .269). Although both groups had comparable recurrence patterns, repeat hepatectomies for recurrence were performed more frequently in the laparoscopic two-stage hepatectomy group (56% vs 0%; P = .006).

CONCLUSION

Laparoscopic two-stage hepatectomy for bilobar colorectal liver metastases is safe and feasible with favorable surgical and oncologic outcomes compared to open two-stage hepatectomy.

Dealing with an insufficient future liver remnant: Portal vein embolization and two-stage hepatectomy

Colorectal liver metastases (CLM) are not always resectable at the time of diagnosis. An insufficient future liver remnant is a factor excluding patients from curative intent resection. To deal with this issue, two-stage hepatectomy was introduced approximately 20 years ago. It is a sequential treatment strategy for bilateral CLM, which consists of preoperative chemotherapy, portal vein embolization, and planned first and second liver resections. This study reviews current evidence supporting use of two-stage hepatectomy.

The Southampton Consensus Guidelines for Laparoscopic Liver Surgery: From Indication to Implementation

OBJECTIVE

The European Guidelines Meeting on Laparoscopic Liver Surgery was held in Southampton on February 10 and 11, 2017 with the aim of presenting and validating clinical practice guidelines for laparoscopic liver surgery.

BACKGROUND

The exponential growth of laparoscopic liver surgery in recent years mandates the development of clinical practice guidelines to direct the speciality's continued safe progression and dissemination.

METHODS

A unique approach to the development of clinical guidelines was adopted. Three well-validated methods were integrated: the Scottish Intercollegiate Guidelines Network methodology for the assessment of evidence and development of guideline statements; the Delphi method of establishing expert consensus, and the AGREE II-GRS Instrument for the assessment of the methodological quality and external validation of the final statements.

RESULTS

Along with the committee chairman, 22 European experts; 7 junior experts and an independent validation committee of 11 international surgeons produced 67 guideline statements for the safe progression and dissemination of laparoscopic liver surgery. Each of the statements reached at least a 95% consensus among the experts and were endorsed by the independent validation committee.

CONCLUSION

The European Guidelines Meeting for Laparoscopic Liver Surgery has produced a set of clinical practice guidelines that have been independently validated for the safe development and progression of laparoscopic liver surgery. The Southampton Guidelines have amalgamated the available evidence and a wealth of experts' knowledge taking in consideration the relevant stakeholders' opinions and complying with the international methodology standards.

Evolution and revolution of laparoscopic liver resection in Japan

Due to important technological developments and improved endoscopic techniques, laparoscopic liver resection (LLR) is now considered the approach of choice and is increasingly performed worldwide. Recent systematic reviews and meta‐analyses of observational data reported that LLR was associated with less bleeding, fewer complications, and no oncological disadvantage; however, no prospective randomized trials have been conducted. LLR will continue to evolve as a surgical approach that improves patient's quality of life. LLR will not totally supplant open liver surgery, and major LLR remains to be technically challenging procedure. The success of LLR depends on individual learning curves and adherence to surgical indications. A recent study proposed a scoring system for stepwise application of LLR, which was based on experience at high‐volume Japanese centers. A cluster of deaths after major LLR was sensationally reported by the Japanese media in 2014. In response, the Japanese Society of Hepato‐Biliary‐Pancreatic Surgery conducted emergency data collection on operative mortality. The results demonstrated that mortality was not higher than that for open procedures except for hemi‐hepatectomy with biliary reconstruction. An online prospective registry system for LLR was established in 2015 to be transparent for patients who might potentially undergo treatment with this newly developed, technically demanding surgical procedure.

Laparoscopic first step approach in the two stage hepatectomy

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

Two-stage hepatectomy, a 10 years experience

Colorectal tumor represents in Europe the second most common cause of cancer death. Surgical resection in case of colorectal liver metastasis remain for patients the only cure. In 2003, Jaeck et al. described a one or two-stage hepatectomy combined with PVE for initially non-resectable colorectal liver metastases. The aim of our study was to retrospectively review all patients who underwent to a two-stage hepatectomy for CLM and evaluate the safety and feasibility of the procedure. We review all patient who underwent two-stage hepatectomy for CLM in our center. From 2004 to March 2014, 57 patients were candidate for a two-stage hepatectomy for CLM. Thirty-two patients (55.9 %) were men and twenty-five women (44.1 %). Median age was 60.9 years old. In forty-six cases, the two-stage hepatectomy was completed. Of these 46 patients, 38 patients completed the procedure with a PVL and 8 underwent a secondary PVE. Seven patients were planned but did not performed PVL after intraoperative evaluation and neither PVE after secondary evaluation due to disease progression. Five cases were treated with a laparoscopic approach for the first step procedure. We had no death in this series. Ten patients developed complications after the first-stage operation and 18 patients had complications after the second stage. The median interval between the two stages was 66 days. Long-term overall survival was 52 months from the first liver surgery. This study demonstrated the feasibility of two-stage hepatectomy without postoperative mortality. In our last experience in selected patient, a laparoscopic first step should be performed. Patients selection is extremely important to propose the best therapeutic option for each one.

Laparoscopic two-stage hepatectomy for bilobar colorectal liver metastases

Background

Despite the gradual diffusion of laparoscopic liver resection, the feasibility and results of laparoscopic two-stage hepatectomy (TSH) for bilobar colorectal liver metastases (CRLM) have not been described frequently. This study aimed to evaluate the feasibility, safety and oncological outcomes of laparoscopic TSH for bilobar CRLM.

Methods

All patients eligible for laparoscopic TSH among those treated for bilobar CRLM from 2000 to 2013 were included. Demographics, tumour characteristics, surgical procedures, and short- and long-term outcomes were analysed.

Results

Laparoscopic TSH was planned in 34 patients with bilobar CRLM, representing 17·2 per cent of all 198 patients treated for bilobar CRLM. Thirty patients received preoperative chemotherapy, and 20 had portal vein occlusion to increase the volume of the remnant liver. Laparoscopic resection of the primary colorectal tumour was integrated within the first-stage hepatectomy in 11 patients. After a median interval of 3·1 months, 26 patients subsequently had a successful laparoscopic second-stage hepatectomy, including 18 laparoscopic right or extended right hepatectomies. The mortality rate for both stages was 3 per cent (1 of 34), and the overall morbidity rate for the first and second stages was 50 per cent (17 of 34) and 54 per cent (14 of 26) respectively. Mean length of hospital stay was 6·1 and 9·0 days respectively. With a median follow-up of 37·8 (range 6–129) months, 3- and 5-year overall survival rates in patients who completed TSH were 78 and 41 per cent respectively. The 3- and 5-year disease-free survival rates were 26 and 13 per cent respectively.

Conclusion

Laparoscopic TSH for bilobar CRLM is safe and does not jeopardize long-term outcomes in selected patients.

Synchronous totally laparoscopic management of colorectal cancer and resectable liver metastases: a single center experience

PURPOSE

The simultaneous management of primary colorectal cancer and synchronous liver metastases has been reported extensively in open surgery. Data regarding feasibility, safety, and outcomes of the laparoscopic procedure is emerging from the experience of a few surgical centers. This paper aims at discussing the technique and results of a one-step laparoscopic approach for colorectal cancer and liver metastases resection on a series of 35 patients.

METHODS

Between January 2008 and December 2013, 18 males and 17 females (median age 71 years) underwent colorectal and hepatic laparoscopic resection for colorectal metastatic cancer.

RESULTS

Thirty-five colorectal resections and 66 liver resections were performed; no conversion to open surgery has been indicated. Median blood loss was 200 ml, median operative time 240 min, and median hospital stay was 8 days (range 4-30). According to Clavien-Dindo classification, two class II complications, two class IIIb complications, and one class IV complication were recorded. Two high-risk patients died within 30 days from surgery.

CONCLUSIONS

This series confirms the feasibility of synchronous laparoscopic colorectal and hepatic resections. To ensure the best outcomes, a careful selection of patients is needed. However, most patients can benefit from this surgical approach.

Laparoscopic liver resection compared to open approach in patients with colorectal liver metastases improves further resectability: Oncological outcomes of a case-control matched-pairs analysis

AIMS

Liver resection is considered the standard treatment of colorectal metastases (CRLM). However, to date, no long term oncological results and data regarding repeat hepatectomy after laparoscopic approach are known. The aim of this study is to analyze single center long-term surgical and oncological outcomes after liver resection for CRLM.

METHODS

A total of 57 open resections (OR) were matched with 57 laparoscopic resections (LR) for CRLM. Matching was based mainly on number of metastases, tumor size, segmental position of lesions, type of hepatectomy and type of resection.

RESULTS

Morbidity rate was significantly less in the LR group (p = 0.002); the length of hospital stay was 6.5 ± 5 days for the LR group and 9.2 ± 4 days for the OR group (p = 0.005). After a median follow up of 53.7 months for the OR group and 40.9 months for the LR group, the 5-y overall survival rate was 65% and 60% respectively (p = 0.36) and the 5-y disease free survival rate was 38% and 29% respectively (p = 0.24). More patients in the LR group received a third hepatectomy for CRLM relapse than in the OR group (80% vs. 14.3% respectively; p = 0.015).

CONCLUSIONS

Laparoscopic resection for CRLM offers advantages in terms of reduced blood loss, morbidity rate and hospital stay. It provides comparable long-term oncological outcomes but can improve further resectability in patients with recurrent disease.