Benefits of Laparoscopic Approach for Resection of Liver Tumors in Cirrhotic Patients

EAES/SAGES evidence-based recommendations and expert consensus on optimization of perioperative care in older adults

BACKGROUND

As the population ages, more older adults are presenting for surgery. Age-related declines in physiological reserve and functional capacity can result in frailty and poor outcomes after surgery. Hence, optimizing perioperative care in older patients is imperative. Enhanced Recovery After Surgery (ERAS) pathways and Minimally Invasive Surgery (MIS) may influence surgical outcomes, but current use and impact on older adults patients is unknown. The aim of this study was to provide evidence-based recommendations on perioperative care of older adults undergoing major abdominal surgery.

METHODS

Expert consensus determined working definitions for key terms and metrics related to perioperative care. A systematic literature review and meta-analysis was performed using the PubMed, Embase, Cochrane Library, and Clinicaltrials.gov databases for 24 pre-defined key questions in the topic areas of prehabilitation, MIS, and ERAS in major abdominal surgery (colorectal, upper gastrointestinal (UGI), Hernia, and hepatopancreatic biliary (HPB)) to generate evidence-based recommendations following the GRADE methodology.

RESULT

Older adults were defined as 65 years and older. Over 20,000 articles were initially retrieved from search parameters. Evidence synthesis was performed across the three topic areas from 172 studies, with meta-analyses conducted for MIS and ERAS topics. The use of MIS and ERAS was recommended for older adult patients particularly when undergoing colorectal surgery. Expert opinion recommended prehabilitation, cessation of smoking and alcohol, and correction of anemia in all colorectal, UGI, Hernia, and HPB procedures in older adults. All recommendations were conditional, with low to very low certainty of evidence, with the exception of ERAS program in colorectal surgery.

CONCLUSIONS

MIS and ERAS are recommended in older adults undergoing major abdominal surgery, with evidence supporting use in colorectal surgery. Though expert opinion supported prehabilitation, there is insufficient evidence supporting use. This work has identified evidence gaps for further studies to optimize older adults undergoing major abdominal surgery.

The impact of hospital volume on liver resection: A systematic review and Bayesian network meta-analysis

BACKGROUND

This study aims to compare the outcomes of high-volume, medium-volume, and low-volume hospitals performing hepatic resections using a network meta-analysis.

METHODS

A literature search until June 2023 was conducted across major databases to identify studies comparing outcomes in high-volume, medium-volume, and low-volume hospitals for liver resection. Bayesian network meta-analysis was conducted, and surface under cumulative ranking area values, odds ratio, and mean difference with 95% credible intervals were reported for postoperative mortality, failure-to-rescue, morbidity, length of stay, and hospital costs.

RESULTS

Twenty studies comprising 248,707 patients undergoing liver resection were included. For the primary mortality outcome, overall and subgroup analyses were performed: group I: high-volume = 5 to 20 resections/year; group II: high-volume = 21 to 49 resections/year; group III: high-volume ≥50 resections/year. Results demonstrated a significant association between hospital volume and mortality (overall-high-volume versus medium-volume: odds ratio 0.66, 95% credible interval 0.49-0.87; high-volume versus low-volume: odds ratio 0.52, 95% credible interval 0.41-0.65; group I-high-volume versus low-volume: odds ratio 0.34, 95% credible interval 0.22-0.50; medium-volume versus low-volume: odds ratio 0.56, 95% credible interval 0.33-0.92; group II-high-volume versus low-volume: odds ratio 0.67, 95% credible interval 0.45-0.91), as well as length of stay (high-volume versus low-volume: mean difference -1.24, 95% credible interval -2.07 to -0.41), favoring high-volume hospitals. No significant difference was observed in failure-to-rescue, morbidity, or hospital costs across the 3 groups.

CONCLUSION

This study supports a positive relationship between hospital volume and surgical outcomes in liver resection. Patients from high-volume hospitals experience superior outcomes in terms of lower postoperative mortality and shorter lengths of stay than medium-volume and low-volume hospitals.

The preoperative M2BPGi score predicts operative difficulty and the incidence of postoperative complications in laparoscopic liver resection

BACKGROUND

Liver fibrosis or cirrhosis frequently makes parenchymal transection more difficult, but the difficulty score of laparoscopic liver resection (LLR), including the IWATE criteria, does not include a factor related to liver fibrosis. Therefore, this study aimed to evaluate M2BPGi as a predictor of the difficulty of parenchymal transection and the incidence of postoperative complications in LLR.

METHODS

Data from 54 patients who underwent laparoscopic partial liver resection (LLR-P) and 24 patients who underwent laparoscopic anatomical liver resection between 2017 and 2019 in our institution were retrospectively analyzed. All cases were classified according to M2BPGi scores, and reserve liver function, intraoperative blood loss, and postoperative complications were compared among these groups.

RESULTS

Sixteen cases (29.6%) were M2BPGi negative (cut-off index < 1.0), 25 cases (46.3%) were 1+ (1.0 ≤ cut-off index < 3.0), and 13 cases (24.1%) were 2+ (cut-off index ≥ 3.0). M2BPGi-positive cases had significantly worse hepatic reserve function (K-ICG: 0.16 vs 0.14 vs 0.08, p < 0.0001). Intraoperative bleeding was significantly greater in M2BPGi-positive cases [50 ml vs 150 ml vs 200 ml, M2BPGi (-) or (1+) vs M2BPGi (2+), p = 0.045]. Postoperative complications (Clavien-Dindo ≥ II) were significantly more frequent in M2BPGi-positive cases [0% vs 4% vs 33%, M2BPGi (-) or (1+) vs M2BPGi (2+), p = 0.001].

CONCLUSION

M2BPGi could predict surgical difficulty and complications in LLR-P. In particular, it might be better not to select M2BPGi (2+) cases as teaching cases because of the massive bleeding during parenchymal transection.

Short-term outcomes of laparoscopic versus open hepatectomy in the elderly patient: systematic review and meta-analysis

BACKGROUND AND AIM

Favorable outcomes of laparoscopic hepatectomy (LH) over open hepatectomy (OH) have been demonstrated. LH offers less postoperative morbidity, less blood loss, and shorter hospital stay, while maintaining oncological safety. Only limited evidence about outcomes of LH in elderly is currently available. Therefore, this study aimed to compare short term outcomes of LH to OH for patients >65 years.

METHODS

A systematic review and meta-analysis were performed according to Cochrane guidelines. Embase, PubMed, Cochrane Library, and Google Scholar were searched to identify eligible studies. Studies were included if they compared LH to OH, and focused on an elderly population, or had a majority of patients >65 years. Perioperative and postoperative outcomes were analyzed.

RESULTS

Thirteen studies with 1174 patients (LH:532, OH:642) were included for analysis. When compared to OH, elderly undergoing LH had significantly less postoperative complications (risk ratio [RR]0.52; 95% confidence interval (CI):0.43-0.63), less blood loss (mean difference [MD]-198.58; 95% CI:-299.88 to -97.28), and shorter length of stay (MD-4.83; 95%CI:-7.91 to -1.84), while oncological safety was non-inferior (RR1.04; 95%CI:1.00-1.08).

CONCLUSIONS

Within the elderly population LH seems to be superior to OH, concerning short-term outcomes. However, for broader applicability more trials are needed including more difficult and major resections.

Current status of radical laparoscopy for treating hepatocellular carcinoma with portal hypertension

The laparoscopic technique is clinically effective in treating hepatocellular carcinoma (HCC) with portal hypertension (PHT). However, existing studies lack systematic arrangement and induction. Here, we review the latest research advancement in laparoscopic technique for treatment of HCC with PHT, based on published literature and our single-institution experience. Our single-center experience reveals no statistical difference in both short- and long-term prognosis of HCC patients after laparoscopic liver resection (LLR), regardless of whether they suffer from PHT, which is consistent with previous studies on the use of LLR for HCC with PHT. Retrieval outcomes indicate existence of short- and long-term prognostic superiority, following laparoscopic treatment, relative to non-laparoscopic treatment. Besides that, LLR offers long-term prognostic advantage compared to laparoscopic radiofrequency ablation. In addition, we review the previous literature and propose corresponding perspectives on the therapy of hypersplenism, the utilization of Pringle maneuver, and the adoption of anatomical hepatectomy during radical laparoscopic treatment. HCC with PHT is not the "forbidden zone" of radical laparoscopic treatment. However, patients’ preoperative liver function should be adequately estimated.

Laparoscopic Versus Open Hepatectomy in Short- and Long-Term Outcomes of the Hepatocellular Carcinoma Patients with Cirrhosis: A Systematic Review and Meta-Analysis

Background: Laparoscopic hepatectomy (LH) has been reported as a safe and efficacious treatment for hepatocellular carcinoma (HCC) patients. However, in cirrhosis patients, LH may be more complex and challenging. So, the short- and long-term outcomes should be well evaluated between LH and open hepatectomy (OH) in HCC patients with cirrhosis. Objectives: To compare the short- and long-term outcomes of LH with OH in HCC patients with cirrhosis. Materials and Methods: The PubMed, EMBASE, and Web of Science were systematically searched to identify the clinical trials published until July 2018 on the comparison of LH and OH in HCC patients with cirrhosis. The statistical analysis was conducted by the Review Manager 5.3 (Cochrane Collaboration, Oxford, United Kingdom). Short-term outcomes included blood loss, operation time, blood transfusion, postoperative complications, mortality, postoperative hospital stay, tumor size, and surgical margin. Long-term outcomes included 1-, 3-, 5-year overall survival (OS) and 1-, 3-, 5-year disease-free survival (DFS). Results: Seventeen studies with 2004 patients were included in this meta-analysis. For short-term outcomes, LH suggested less blood loss, lower blood transfusion rates, reduced occurrence of postoperative complications, wider surgical margin, shorter postoperative hospital stay, and declined rate of mortality (all P < .05). However, there was no significant difference in operation time (P = .67) between the two groups, whereas tumor size was larger in OH (P = .004). As to long-term outcomes, 1-, 3-, 5-year OS and 1-year DFS were higher in LH group (all P < .05). Nevertheless, there were no significant differences in 3- and 5-year DFS (P = .23 and .83, respectively). Conclusions: For the HCC patients with cirrhosis, current evidence suggests that LH shows not only better outcomes in short term, but also a comparable and even improved long-term prognosis.

Minor laparoscopic liver resection as day-case surgery (without overnight hospitalisation): a pilot study

BACKGROUND

Day-case surgery (DCS) has become increasingly popular over recent years, as has laparoscopic liver resection (LLR) for the treatment of benign or malignant liver tumours. The purpose of this prospective study was to demonstrate the feasibility of minor LLR as DCS.

METHODS

Prospective, intention-to-treat, non-randomised study of patients undergoing minor LLR between July 2015 and December 2017. Exclusion criteria were resection by laparotomy, major LLR, difficult locations for minor LLR, history of major abdominal surgery, hepatobiliary procedures without liver parenchyma resection, cirrhosis with Child > A and/or portal hypertension, significant medical history and exclusion criteria for DCS. The primary endpoint was the unplanned overnight admission rate. Secondary endpoints were the reason for exclusion, complication data, criteria for DCS evaluation, satisfaction and compliance with the protocol.

RESULTS

One hundred sixty-seven patients underwent liver resection during the study period. LLR was performed in 92 patients (55%), as DCS in 23 patients (25%). Reasons for minor LLR were liver metastasis (n = 9), hepatic adenoma (n = 5), hepatocellular carcinoma (n = 4), ciliated hepatic foregut cyst (n = 2) and other benign tumours (n = 3). All day-case minor LLR, except two patients, consisted of single wedge resection, while one patient underwent left lateral sectionectomy. There were four unplanned overnight admissions (17.4%), one unscheduled consultation (4.3%), two hospital readmissions (8.6%) and no major complications/mortality. Compliance with the protocol was 69.5%. Satisfaction rate was 91%.

CONCLUSION

In selected patients, day-case minor LLR is feasible with acceptable complication and readmission rates. Day-case minor LLR can therefore be legitimately proposed in selected patients.