Laparoscopic Versus Open Left Lateral Segmentectomy for Large Hepatocellular Carcinoma: A Propensity Score-Matched Analysis

A meta-analysis: laparoscopic versus open liver resection for large hepatocellular carcinoma

BACKGROUND

The indication of laparoscopic liver resection (LLR) for treating large hepatocellular carcinoma (HCC) is controversial. In this study, we compared the short-term and long-term outcomes of LLR and open liver resection (OLR) for large HCC.

MATERIAL AND METHODS

We searched eligible articles about LLR versus OLR for large HCC in PubMed, Cochrane Library, and EMBASE and performed a meta-analysis.

RESULTS

Eight publications involving 1,338 patients were included. Among them, 495 underwent LLR and 843 underwent OLR. The operation time was longer in the LLR group (MD: 22.23, 95% CI: 4.14-40.33, p = 0.02). but the postoperative hospital stay time was significantly shorter (MD : -4.88, CI: -5.55 to -4.23, p < 0.00001), and the incidence of total postoperative complications and major complications were significantly fewer (OR: 0.49, 95% CI:0.37-0.66, p < 0.00001; OR: 0.54, 95% CI:0.36 - 0.82, p = 0.003, respectively). Patients in the laparoscopic group had no significant difference in intraoperative blood loss, intraoperative transfusion rate, resection margin size, R0 resection rate, three-year overall survival (OS) and three-year disease-free survival (DFS).

CONCLUSION

LLR for large HCC is safe and feasible. This surgical strategy will not affect the long-term outcomes of patients.

Short- and long-term outcomes of laparoscopic versus open liver resection for large hepatocellular carcinoma: a propensity score study

PURPOSE

Laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) remains controversial, especially for tumors larger than 5 cm. We compared the short- and long-term outcomes of laparoscopic and open liver resection (OLR) for large HCC.

METHODS

Patients with large HCC after curative hepatectomy were enrolled. To compare the short-term outcomes, propensity score matching (PSM) and inverse probability treatment weighting (IPTW) were performed to reduce the effect of confounding factors, respectively. Subsequently, Cox-regression analyses were conducted to identify the independent risk factors associated with decreased recurrence-free survival (RFS) and poor overall survival (OS).

RESULT

There were 265 patients enrolled in the final analysis: 146 who underwent OLR and 119 who underwent LLR. There was no significant difference between the OLR and LLR groups according to PSM and IPTW analysis (all P > 0.05). Multivariable analysis revealed that LLR was not independently associated with poorer OS (HR 1.15, 95% CI 0.80-1.67, P = 0.448) or RFS (HR 1.22, 95% CI 0.88-1.70, P = 0.238).

CONCLUSION

There were no significant differences in perioperative complications or long-term prognosis between LLR and OLR for large HCC, which provides evidence for standard laparoscopic surgical practice with adequate surgeon experience and careful patient selection.

Challenging Scenarios and Debated Indications for Laparoscopic Liver Resections for Hepatocellular Carcinoma

Laparoscopic liver resections (LLRs) have been increasingly adopted for the treatment of hepatocellular carcinoma (HCC), with safe short- and long-term outcomes reported worldwide. Despite this, lesions in the posterosuperior segments, large and recurrent tumors, portal hypertension, and advanced cirrhosis currently represent challenging scenarios in which the safety and efficacy of the laparoscopic approach are still controversial. In this systematic review, we pooled the available evidence on the short-term outcomes of LLRs for HCC in challenging clinical scenarios. All randomized and non-randomized studies reporting LLRs for HCC in the above-mentioned settings were included. The literature search was run in the Scopus, WoS, and Pubmed databases. Case reports, reviews, meta-analyses, studies including fewer than 10 patients, non-English language studies, and studies analyzing histology other than HCC were excluded. From 566 articles, 36 studies dated between 2006 and 2022 fulfilled the selection criteria and were included in the analysis. A total of 1859 patients were included, of whom 156 had advanced cirrhosis, 194 had portal hypertension, 436 had large HCCs, 477 had lesions located in the posterosuperior segments, and 596 had recurrent HCCs. Overall, the conversion rate ranged between 4.6% and 15.5%. Mortality and morbidity ranged between 0.0% and 5.1%, and 18.6% and 34.6%, respectively. Full results according to subgroups are described in the study. Advanced cirrhosis and portal hypertension, large and recurrent tumors, and lesions located in the posterosuperior segments are challenging clinical scenarios that should be carefully approached by laparoscopy. Safe short-term outcomes can be achieved provided experienced surgeons and high-volume centers.

Survival analysis between laparoscopic and open hepatectomy for hepatocellular carcinoma: a meta-analysis based on reconstructed time-to-event data

BACKGROUND/PURPOSE OF THE STUDY

Laparoscopic hepatectomy (LH) has been widely used in the treatment of hepatocellular carcinoma (HCC). It is generally believed that the long-term outcomes of LH are not inferior to open hepatectomy (OH). However, the quality of evidence is low. The purpose of this study was to reconstruct time-to-event data for meta-analysis based on Kaplan-Meier curves from propensity-score matched studies and compare survival rates following LH and OH for hepatocellular carcinoma.

METHODS

All published propensity-score matched studies reported in English that compared LH and OH for hepatocellular carcinoma with Kaplan-Meier curves were screened. Patients' survival information was reconstructed with the aid of a computer vision program. Different models (fixed-effects model for two-stage survival analysis and Cox regression for one-stage survival analysis) were performed for sensitivity analysis. In addition to the primary meta-analysis, two specific subgroup analyses were performed on patients by types of resection, cirrhosis status.

RESULTS

Time-to-event data were extracted from 45 propensity-score matched studies (N = 8905). According to the time-to-event data and the reconstructed Kaplan-Meier curves, the cumulative overall survival rate was 49.0% and 50.9% in the LH and OH cohorts, respectively, a log-rank test did not demonstrate statistical significance (p > 0.05). The cumulative recurrence-free survival (RFS) probability was both close to 0.0%. The median RFS time was 49.1 (95% CI 46.1 ~ 51.7) and 44.3 (95% CI 41 ~ 46.1) months. The difference in disease status was statistically significant by the Log-rank test (p < 0.05). Using the random-effects model of two-stage analysis, the minor hepatectomy subgroup (HR = 1.32, 95% CI [1.09, 1.55], I² = 6.2%, p = 0.383) and the shared fragile model of one-stage analysis (HR = 1.44 95% CI [1.23, 1.69], p < 0.001) suggested that LH could significantly prolong RFS of patients compared with OH. This result was consistent with sensitivity analysis using different models.

CONCLUSION

This study was the first reconstructed time-to-event data based on a high-quality propensity-score matching study to compare the survival outcomes of LH and OH in the treatment of HCC. Results suggested that LH can improve RFS in patients with HCC undergoing minor hepatectomy and may also benefit long-term RFS in overall patients.

Recent advances in the surgical management of hepatocellular carcinoma

The incidence of hepatocellular carcinoma (HCC) is increasing, despite effective antiviral treatment for hepatitis B (HBV) and C virus infection and the application of preventive measures such as vaccination at birth against HBV infection. This is mainly due to the increase in metabolic syndrome and its hepatic components, nonalcoholic fatty liver disease and steatohepatitis. Liver resection and transplantation are the main treatment options, offering long-term survival and potential cure. In this review, the recent advances in the surgical management of HCC are presented. More specifically, the role of liver resection in the intermediate and advanced stages, according to the Barcelona Clinic Liver Cancer classification, is analyzed. In addition, the roles of minimally invasive surgery and of living-related liver transplantation in the management of patients with HCC are discussed. Finally, recent data on the role of molecular markers in the early diagnosis and recurrence of HCC are presented. The management of HCC is complex, as there are several options for each stage of the disease. In order for, each patient to get the maximum benefit, an individualized approach is suggested, in specialized liver units, where cases are discussed in multidisciplinary tumor boards.