Surgical and oncologic outcomes following laparoscopic versus open liver resection for hepatocellular carcinoma: A meta-analysis

Minimally Invasive Donors Right Hepatectomy versus Open Donors Right Hepatectomy: A Meta-Analysis

BACKGROUND

How to obtain a donor liver remains an open issue, especially in the choice of minimally invasive donors right hepatectomy versus open donors right hepatectomy (MIDRH versus ODRH). We conducted a meta-analysis to clarify this question.

METHODS

A meta-analysis was performed in PubMed, Web of Science, EMBASE, Cochrane Central Register, and ClinicalTrials.gov databases. Baseline characteristics and perioperative outcomes were analyzed.

RESULTS

A total of 24 retrospective studies were identified. For MIDRH vs. ODRH, the operative time was longer in the MIDRH group (mean difference [MD] = 30.77 min; p = 0.006). MIDRH resulted in significantly less intraoperative blood loss (MD = -57.86 mL; p < 0.00001), shorter length of stay (MD = -1.22 days; p < 0.00001), lower pulmonary (OR = 0.55; p = 0.002) and wound complications (OR = 0.45; p = 0.0007), lower overall complications (OR = 0.79; p = 0.02), and less self-infused morphine consumption (MD = -0.06 days; 95% CI, -1.16 to -0.05; p = 0.03). In the subgroup analysis, similar results were observed in pure laparoscopic donor right hepatectomy (PLDRH) and the propensity score matching group. In addition, there were no significant differences in post-operation liver injury, bile duct complications, Clavien-Dindo ≥ 3 III, readmission, reoperation, and postoperative transfusion between the MIDRH and ODRH groups.

DISCUSSION

We concluded that MIDRH is a safe and feasible alternative to ODRH for living donators, especially in the PLDRH group.

Pure laparoscopic vs open right hepatectomy in patients with hepatocellular carcinoma: A propensity score-matched analysis

BACKGROUND/PURPOSE

Since minimally invasive surgery has been incorporated in overall surgery, pure laparoscopic technology is involved in most hepatectomies, including right hepatectomy, in patients with hepatocellular carcinoma (HCC). However, its feasibility and safety in right hepatectomy are still controversial owing to the limited literature. This study aimed to compare the short- and long-term outcomes of pure laparoscopic right hepatectomy (PLRH) with those of open right hepatectomy (ORH) in patients with HCC.

METHODS

The prospectively collected medical records of 327 patients with HCC who underwent right hepatectomy between January 2010 and April 2020 at Seoul National University Hospital were retrospectively reviewed. We performed 1:1 propensity score matching between the PLRH and ORH groups. The primary end point was short-term outcomes, including hospital stay, blood loss, and morbidity; the secondary end point was long-term outcomes, including overall and recurrence-free survival.

RESULTS

Forty-nine patients were included in each group. Patients who underwent PLRH had a shorter postoperative hospital stay than those who underwent ORH (12.2 vs 8.9 days; P < .001). The requirement for blood transfusion was significantly lower in the PLRH group than in the ORH group (10.2% vs 2.0%; P = .010). The operative time (P = .479) and proportion of major complications (P = .487) were comparable between the groups. There were no significant differences in overall survival (P = .524) and the recurrence-free survival rate (P = .576) between the groups.

CONCLUSIONS

Postoperative outcomes, including oncological outcomes, were comparable between PLRH and ORH, showing that PLRH can be a safe and feasible option to replace ORH in patients with HCC.

Outcomes and Patient Selection in Laparoscopic vs. Open Liver Resection for HCC and Colorectal Cancer Liver Metastasis

Hepatocellular carcinoma (HCC) and colorectal liver metastasis (CRLM) are the two most common malignant tumors that require liver resection. While liver transplantation is the best treatment for HCC, organ shortages and high costs limit the availability of this option for many patients and make resection the mainstay of treatment. For patients with CRLM, surgical resection with negative margins is the only potentially curative option. Over the last two decades, laparoscopic liver resection (LLR) has been increasingly adopted for the resection of a variety of tumors and was found to have similar long-term outcomes compared to open liver resection (OLR) while offering the benefits of improved short-term outcomes. In this review, we discuss the current literature on the outcomes of LLR vs. OLR for patients with HCC and CRLM. Although the use of LLR for HCC and CRLM is increasing, it is not appropriate for all patients. We describe an approach to selecting patients best-suited for LLR. The four common difficulty-scoring systems for LLR are summarized. Additionally, we review the current evidence behind the emerging robotically assisted liver resection technology.

Impact of Three-Dimensional (3D) Visualization on Laparoscopic Hepatectomy for Hepatocellular Carcinoma

BACKGROUND

The impact of three-dimensional (3D) visualization on laparoscopic hepatectomy for hepatocellular carcinoma is largely unknown.

METHODS

A retrospective review with propensity-score matched analysis of 3D and two-dimensional (2D) laparoscopic hepatectomy performed in a tertiary hepatobiliary surgery center.

RESULTS

Since the availability of 3D laparoscopy, the proportion of laparoscopic major hepatectomies has significantly expanded (1.7% vs. 24.0%, p < 0.0001) and the percentage of difficult resections among patients who underwent laparoscopic hepatectomy has also increased (12.6% vs. 40.0%, p = 0.0001). A total of 305 patients (92 in the 3D group and 213 in the 2D group) underwent laparoscopic hepatectomy between 2002 and 2019. The 3D group had better liver function, larger tumors at more difficult locations, more major resections, and more difficult surgeries. After propensity score matching, 144 patients were analyzed (72 in both the 3D and 2D groups). Patients were comparable in terms of liver status, tumor status, and complexity of liver surgery. Operative time (218 vs. 218 mins, p = 0.50) and blood loss (0.2 vs. 0.2L, p = 0.49) were comparable between the two groups, however overall complications were higher in the 2D group (1.4 vs. 11.1%, p = 0.03). Patients who underwent 3D laparoscopic major hepatectomy had a shorter hospital stay than their comparable counterparts operated through an open approach (7 vs. 6 days, p = 0.003).

CONCLUSIONS

3D visualization enhanced the feasibility of laparoscopic major hepatectomy and difficult laparoscopic liver resection. 3D resection was potentially associated with fewer operative morbidities and the 3D laparoscopic approach did not jeopardize the outcome of major hepatectomy.

Expression of Notch-Hif-1α signaling pathway in liver regeneration of rats

Objective

To investigate whether the Notch–Hif-1α signaling pathway is involved in liver regeneration.

Methods

Rats were divided into two groups and treated with daily intraperitoneal injections of saline (control) or the gamma-secretase inhibitor, Fli-06, for 2 days. Two-thirds of the rat livers were resected and rats were later euthanized at specific time points post-resection to analyze the remnant livers. Each group's liver/body weight ratio was calculated, and immunostaining and western blotting were used to determine the cell proliferation marker, PCNA and Ki-67 expression. Real-time PCR and western blotting were used to compare the mRNA expression of Notch homolog-1 (Notch1), hairy and enhancer of split-1 (Hes1), and vascular endothelial growth factor (Vegf), and the protein expression of NICD and HIF-1α, respectively.

Results

The liver/body weight ratios and number of Ki-67- and PCNA-positive cells were significantly lower in the experimental group than the control group, indicating lower levels of liver regeneration following the disruption of Notch signaling by Fli-06. The Hes1 and Vegf mRNA levels and NICD and HIF-1α protein expression levels were all down-regulated by Fli-06 treatment.

Conclusion

Notch–Hif-α signaling pathway activation plays an important role in liver regeneration, where it may contribute toward liver cell proliferation.

Unravelling the Complexity Myth for Minimally Invasive Right Hepatectomy: Liver Parenchymal Features and their Correlation to Objective Outcomes in Major Anatomical Resections

BACKGROUND

Minimally invasive approaches to major liver resection have been limited by presumed difficulty of the operation. While some concerns arise from mastering the techniques, factors such as tumor size and liver parenchymal features have anecdotally been described as surrogates for operative difficulty. These factors have not been systematically studied for minimally invasive right hepatectomy (MIRH).

METHODS

Seventy-five patients who underwent MIRH during 2007-2016 by the senior author were evaluated; these were compared to control group of open right hepatectomy. Demographics, operative, and post-operative variables were collected. Operative times and estimated blood loss, two objective parameters of operative difficulty were correlated to volume of hepatic resection, parenchymal transection diameter and liver parenchymal features using regression analysis.

RESULTS

Thirty-eight (50.6%) resections were performed for malignant indications. Average tumor size was 5.7 cm (±3.6), mean operative time was 196 min (±74), and mean EBL was 220 mL (±170). Average transection diameter was 10.1 cm (±1.7). There was no correlation between operative difficulty with parenchymal transection diameter or presence of steatosis. Blood loss was higher with increased right hepatic lobe volume and body mass index.

CONCLUSIONS

This analysis of a very defined anatomical resection suggests that the often quoted radiographic and pathologic features indicative of a challenging procedure were not significant in determining operative difficulty.

Laparoscopic Liver Resection: A South American Experience with 2887 Cases

BACKGROUND

Laparoscopic liver resections (LLR) have been increasingly performed in recent years. Most of the available evidence, however, comes from specialized centers in Asia, Europe and USA. Data from South America are limited and based on single-center experiences. To date, no multicenter studies evaluated the results of LLR in South America. The aim of this study was to evaluate the experience and results with LLR in South American centers.

METHODS

From February to November 2019, a survey about LLR was conducted in 61 hepatobiliary centers in South America, composed by 20 questions concerning demographic characteristics, surgical data, and perioperative results.

RESULTS

Fifty-one (83.6%) centers from seven different countries answered the survey. A total of 2887 LLR were performed, as follows: Argentina (928), Brazil (1326), Chile (322), Colombia (210), Paraguay (9), Peru (75), and Uruguay (8). The first program began in 1997; however, the majority (60.7%) started after 2010. The percentage of LLR over open resections was 28.4% (4.4-84%). Of the total, 76.5% were minor hepatectomies and 23.5% major, including 266 right hepatectomies and 343 left hepatectomies. The conversion rate was 9.7%, overall morbidity 13%, and mortality 0.7%.

CONCLUSIONS

This is the largest study assessing the dissemination and results of LLR in South America. It showed an increasing number of centers performing LLR with the promising perioperative results, aligned with other worldwide excellence centers.

Learning Curve in Robot-Assisted Laparoscopic Liver Resection

BACKGROUND

The objective of this study was to evaluate the learning curve effect on the safety and feasibility of robot-assisted liver resection (RALR).

METHODS

In 140 consecutive cases, all data about demographic, surgical procedure, postoperative course were collected prospectively and analyzed. Risk-adjusted cumulative sum model was used for determining the learning curve based on the need for conversion.

RESULTS

Among all 140 patients, no patients suffered from any organ dysfunction postoperatively and the operative mortality was 0%. The CUSUM analysis showed that at the 30th consecutive patient, the open conversion rate reached to the average value, and it further improved thereafter. In the last 70 patients, only 3 patients (4.3%) required conversion and 7 patients (10%) needed blood transfusion. Only 1 patient (1.3%) out of 79 patients with HCC had a positive resection margin. Univariate analyses showed the following risk factors associated with significantly higher risks of conversion (P < 0.05): tumor number > 1, lesions in segments 1/4a/7/8, right posterior sectionectomy, and lesions which were beyond the indications of the Louisville statement. Multivariate logistic analysis revealed that both tumor number > 1 (OR: 2.10, P < 0.05) and right posterior sectionectomy (OR: 11.19, P < 0.01) were risk factors of conversion.

CONCLUSIONS

The robotic approach for hepatectomy is safe and feasible. A learning curve effect was demonstrated in this study after the 30th consecutive patient. The long-term oncological outcomes of robotic hepatectomy still need further investigation.

Early Morbidity and Mortality after Minimally Invasive Liver Resection for Hepatocellular Carcinoma: a Propensity-Score Matched Comparison with Open Resection

BACKGROUND

The impact of minimally invasive surgery on the short-term outcomes of patients with hepatocellular carcinoma (HCC) undergoing liver resection remains poorly defined.

METHODS

The ACS-NSQIP-targeted hepatectomy database was used to identify patients who underwent liver resection for HCC during 2014-2016. A 1:1 propensity score matching was created between patients who underwent open (OLR) vs. minimally invasive liver resection (MILR) based on age, ASA score, liver resection type, liver texture, and stage of disease. The short-term outcomes of patients undergoing OLR vs. MILR were compared.

RESULTS

Among a total cohort of 1816 patients, propensity score matching resulted in 728 liver resections: 364 (50%) OLR and 364 (50%) MILR. Overall morbidity (29% vs. 23%, P = 0.04) was greater among patients undergoing OLR compared with MILR, whereas mortality did not differ between the two approaches (2% vs 1%, P = 0.57). MILR was associated with significant reductions in hospital LOS (6 vs. 4 days, P < 0.0001) but no difference in operative time (188 vs. 171 min, P = 0.13). On multivariate logistic regression analysis, age ≥ 65 (OR:1.6, 95%CI: 1.1-2.3, P = 0.0065), ASA class ≥ 3 (OR:2.7, 95%CI: 1.5-4.7, P = 0.0003), preoperative blood transfusion (OR:9.7, 95%CI: 1.06-90.3, P = 0.04), T ≥ 3 (OR:1.9, 95%CI: 1.09-3.4, P = 0.02), operative time > 200 min (OR:1.8, 95%CI: 1.2-2.5, P = 0.0011), and OLR (OR:1.4, 95%CI: 1.002-2.03, P = 0.04) were associated with increased odds of overall morbidity.

CONCLUSIONS

MILR for HCC is associated with a shorter hospital LOS and reduced postoperative complication rates, even after controlling for important patient and clinicopathologic confounders, compared to OLR. Efforts to expand the use of MILR for hepatobiliary surgery are warranted.

Minimally invasive donor hepatectomy, are we ready for prime time?

Minimally invasive surgery potentially reduces operative morbidities. However, pure laparoscopic approaches to donor hepatectomy have been limited by technical complexity and concerns over donor safety. Reduced-wound donor hepatectomy, either in the form of a laparoscopic-assisted technique or by utilizing a mini-laparotomy wound, i.e., hybrid approach, has been developed to bridge the transition to pure laparoscopic donor hepatectomy, offering some advantages of minimally invasive surgery. To date, pure laparoscopic donor left lateral sectionectomy has been validated for its safety and advantages and has become the standard in experienced centres. Pure laparoscopic approaches to major left and right liver donation have been reported for their technical feasibility in expert hands. Robotic-assisted donor hepatectomy also appears to be a valuable alternative to pure laparoscopic donor hepatectomy, providing additional ergonomic advantages to the surgeon. Existing reports derive from centres with tremendous experience in both laparoscopic hepatectomy and donor hepatectomy. The complexity of these procedures means an arduous transition from technical feasibility to reproducibility. Donor safety is paramount in living donor liver transplantation. Careful donor selection and adopting standardized techniques allow experienced transplant surgeons to safely accumulate experience and acquire proficiency. An international prospective registry will advance the understanding for the role and safety of pure laparoscopic donor hepatectomy.

Laparoscopic versus Open Surgery for Hepatocellular Carcinoma: A Meta-Analysis of High-Quality Case-Matched Studies

OBJECTIVE

To present a meta-analysis of high-quality case-matched studies comparing laparoscopic (LH) and open hepatectomy (OH) for hepatocellular carcinoma (HCC).

METHODS

Studies published up to September 2017 comparing LH and OH for HCC were identified. Selection of high-quality, nonrandomized comparative studies (NRCTs) with case-matched design was based on a validated tool (Methodological Index for Nonrandomized Studies) since no randomized controlled trials (RCTs) were published. Morbidity, mortality, operation time, blood loss, hospital stay, margin distance, recurrence, and survival outcomes were compared. Subgroup analyses were carried out according to the surgical extension (minor or major hepatectomy).

RESULTS

Twenty studies with a total of 830 patients (388 in LH and 442 in OH) were identified. For short-term surgical outcomes, LH showed less morbidity (RR = 0.55; 95% CI, 0.47~0.65; P < 0.01), less mortality (RR = 0.43; 95% CI, 0.18~1.00; P = 0.05), less blood loss (WMD = -93.21 ml, 95% CI, -157.33~-29.09 ml; P < 0.01), shorter hospital stay (WMD = -2.86, 95% CI, -3.63~-2.08; P < 0.01), and comparable operation time (WMD = 9.15 min; 95% CI: -7.61~25.90, P = 0.28). As to oncological outcomes, 5-year overall survival rate was slightly better in LH than OH (HR = 0.66, 95% CI: 0.52~0.84, P < 0.01), whereas the 5-year disease-free survival rate was comparable between two groups (HR = 0.88, 95% CI: 0.74~1.06, P = 0.18).

CONCLUSION

This meta-analysis has highlighted that LH can be safely performed in selective patients and improves surgical outcomes as compared to OH. Given the limitations of study design, especially the limited cases of major hepatectomy, methodologically high-quality comparative studies are needed for further evaluation.

Current topics in the surgical treatments for hepatocellular carcinoma

Treatment strategy for hepatocellular carcinoma (HCC) requires optimal selection of therapies based on various factors related to tumor condition and liver functional reserve. Although several evidence-based guidelines have been proposed for the treatment of HCC, the criteria and range of indications differ among these guidelines according to the circumstances of each country. In European nations and the USA, patients with the Barcelona Clinic Liver Cancer stage 0-A are subjects for surgical resection, whereas in Asian countries, even those with the intermediate stage are regarded as surgical candidates. Furthermore, since the recent introduction and rapidly widely spreading use of laparoscopic liver resection, this technique has become an important treatment option for surgical resection. In this review article, we overview the current topics of treatment of HCC with a special focus on surgical therapy.

Perioperative and oncological outcomes of laparoscopic anatomical hepatectomy for hepatocellular carcinoma introduced gradually in a single center

BACKGROUND

Anatomical hepatectomy is an ideal curative treatment for hepatocellular carcinoma (HCC). We have standardized our laparoscopic anatomical hepatectomy (LAH) procedure, gradually extending its indications. In the present study, we describe our experience and the perioperative and oncological outcomes of LAH for HCC compared to those of open anatomical hepatectomy (OAH) during the gradual introduction of LAH.

METHODS

Seventy patients with primary HCC underwent anatomical hepatectomy in our institution from November 2008 to April 2014. As we gained experience with LAH, our indications for choosing LAH over OAH gradually expanded. Ultimately, 40 and 30 patients underwent LAH and OAH, respectively. Perioperative and oncological outcomes were compared between the two groups.

RESULTS

There were no significant differences in age, sex, background of liver disease, liver function, tumor size, tumor number, or type of liver resection between the two groups. Major complications and mortality rates were similar between the LAH and OAH groups (12.5% vs. 20%; p = 0.582, and 0% vs. 3.3%; p = 0.429, respectively). The median follow-up time after surgery was 40.5 months in the LAH group and 32.9 months in the OAH group (p = 0.835). The 1-, 3-, and 5-year overall survival rates were 89.9, 84.7, and 70.9%, in the LAH group, and 89.8, 68.0, and 63.1% in the OAH group, respectively (p = 0.255). The 1-, 3-, and 5-year disease-free survival rates were 79.5, 58.0, and 42.5%, in the LAH group, and 72.4, 56.1, and 50.4% in the OAH group, respectively (p = 0.980).

CONCLUSIONS

Through gradual introduction of LAH, we obtained comparable results to those achieved with OAH. LAH can be a feasible surgical treatment for primary HCC, with good oncological outcomes.

Medical Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) typically occurs in patients with advanced liver disease, so therapeutic decisions must account for the degree of underlying liver dysfunction and patient performance status in addition to tumor burden. Curative treatment options, including liver transplantation, surgical resection, and local ablative therapies, offer 5-year survival rates exceeding 60% but are restricted to patients with early-stage HCC. Surgical resection and local ablative therapies are also limited by high recurrence rates, highlighting a need for adjuvant and/or neoadjuvant therapies. A majority of patients with HCC are diagnosed beyond an early stage, when the tumor is no longer amenable to curative options. For patients with liver-localized HCC in whom curative options are not possible, transarterial therapies, either chemoembolization or radioembolization, can prolong survival but are rarely curative. Sorafenib and regorafenib are the only approved first-line and second-line systemic therapies, respectively, with a survival benefit for patients with advanced HCC; however, the benefit is primarily observed in patients with intact liver function and good performance status. There are several ongoing phase II and III trials evaluating novel systemic therapies, including immunotherapies. Patients with poor performance status or severe hepatic dysfunction do not derive any survival benefit from HCC-directed therapy and have a median survival of approximately 6 months. These patients should be treated with best supportive care, with a focus on maximizing quality of life. Multidisciplinary care has been shown to improve appropriateness of treatment decisions and overall survival and should be considered standard of care for patients with HCC.

Meta-analysis of laparoscopic vs open liver resection for hepatocellular carcinoma

Laparoscopic liver resections (LLR) are widely accepted as safe and effective procedures for the management of hepatocellular carcinoma (HCC) in the hands of experienced surgeons. The efficacy and extent of benefits of pure as well as hand-assisted laparoscopic and laparoscopy-assisted liver resection over open liver resection (OLR) have been investigated by numerous studies during the last 10 years. The aim of our meta-analysis is to investigate the effect of LLR in short- and long-term outcomes compared to OLR in patients operated for HCC. A total of 5203 patients from forty-four studies were included in our meta-analysis reporting for short- and long-term results for both LLR and OLR for HCC. Among them, 1830 underwent pure laparoscopic hepatectomy, 282 underwent pure laparoscopic or hand-assisted laparoscopic or laparoscopy-assisted hepatectomy, and 3091 were operated through open approach. LLRs were found to be significantly associated with lower blood loss, need for blood transfusion, successful achievement of R0 resection as well as wider resection margin, shorter hospital stay, lower morbidity and 30-day mortality rates. Operative time, tumor recurrence, 1-, 3-, and 5-year overall survival as well as 1-, 3-, and 5-year disease-free survival were not found different between the groups. This meta-analysis clearly demonstrates the superiority of laparoscopic resection over the open approach for patients with small HCC.

Totally laparoscopic anatomical liver resection for centrally located tumors: A single center experience

Laparoscopic major hepatectomy is a common procedure that has been reported frequently; however, laparoscopic resection of centrally located tumors involving segments 4, 5, and 8 remains a technically difficult procedure because it requires 2 transection planes and dissection of numerous branches of the hepatic vein and glissonean capsule compared to hemi-hepatectomy. Here, we present 7 cases of totally laparoscopic right anterior sectionectomy (Lap-RAS) and 3 cases of totally laparoscopic central bisectionectomy (Lap-CBS).Between May 2013 and January 2015, 10 totally laparoscopic anatomical resections of centrally located tumors were performed in our institution. The median age of the patients was 54.2 (38-72) years and the median ICG-R15 was 10.4 (3.9-17.4). There were 8 patients with hepatocellular carcinoma (HCC) and 2 with metastatic colorectal cancer. All the HCC patients has the liver function impairment on the degree of Child-Pugh score A.The mean operation time was 330 ± 92.7 minutes with an estimated blood loss of 325 ± 234.5 mL. Only 1 patient required transfusion during surgery. Mean postoperative hospital stay was 9.5 ± 3.4 day and postop complication was reported only 1 case that has the fluid collection at the resection margin of the liver. Mean resection margin was 8.5 ± 6.1 mm and tumor size was 2.9 ± 1.9 cm.Totally lap-RAS and lap-CBS are feasible operative procedures in patients with centrally located tumor of the liver and particularly in patients with limited liver function such as those with cirrhosis.

Current status of laparoscopic liver resection for hepatocellular carcinoma

Laparoscopic liver resection (LLR) is becoming widely accepted for the treatment of hepatocellular carcinoma (HCC). Laparoscopic left lateral sectionectomy and minor laparoscopic liver resection are now considered standard approaches, especially for tumors located in the anterolateral segments of the liver. Laparoscopic left lateral sectionectomy in adult donors is also gaining acceptance for child liver transplantation in many centers. Major LLRs, including left hepatectomy and right hepatectomy, have been recently attempted. Laparoscopic donor hepatectomy is becoming more popular owing to increasing demand from young living donors who appreciate its minimal invasiveness and excellent cosmetic outcomes. Several centers have performed total laparoscopic donor right hepatectomy in adult-to-adult living donor liver transplantation. Many meta-analyses have shown that LLR is better than open liver resection in terms of short-term outcomes, principally cosmetic outcomes. Although no randomized control trials have compared LLR with open liver resection, the long-term oncologic outcomes were similar for both procedures in recent case-matched studies.

Management of hepatocellular carcinoma: an overview of major findings from meta-analyses

This paper aims to systematically review the major findings from meta-analyses comparing different treatment options for hepatocellular carcinoma (HCC). A total of 153 relevant papers were searched via the PubMed, EMBASE, and Cochrane library databases. They were classified according to the mainstay treatment modalities (i.e., liver transplantation, surgical resection, radiofrequency ablation, transarterial embolization or chemoembolization, sorafenib, and others). The primary outcome data, such as overall survival, diseases-free survival or recurrence-free survival, progression-free survival, and safety, were summarized. The recommendations and uncertainties regarding the treatment of HCC were also proposed.

Laparoscopic Right Hepatectomy for Cirrhotic Patients: Takasaki's Hilar Control and Caudal Approach

BACKGROUND

Cirrhotic patients bearing hepatocellular carcinomas (HCC) derive benefits from laparoscopic hepatectomy1 ^- 6 such as reduced bleeding, less overall and liver-specific complications, and fewer adhesions in the case of future reoperation or transplantation.7 ^- 10 Bleeding is concerning in the setting of cirrhosis,11 ^- 15 and adequate inflow control reduces blood loss. The caudal approach is the laparoscopic counterpart of the anterior approach to open surgery. It implies in parenchymal transection initiated from the visceral surface of the liver after limited hepatic mobilization, reducing the risk of increased circulating tumoral cells.16 ^- 18 Venous outflow transection and completion of ligament mobilization are left as last steps.

METHODS

A 46 years-old-male with hepatitis C virus and alcoholic cirrhosis was diagnosed with a 4-cm HCC (right hepatic lobe). Expected future liver remnant was 45 % of his total liver volume. A totally laparoscopic right hepatectomy was performed using six ports, and the specimen was removed through a Pfannenstiel auxiliary incision. A 10-mm 30° scope was used. The pneumoperitoneum pressure was set to 12 mmHg. The right hepatic pedicle, the caudate lobe, and the major hepatic veins were managed with laparoscopic vascular staplers.

RESULTS

Surgery was performed with limited liver mobilization and en bloc extrafascial right pedicle control (Takasaki's technique),19 followed by caudal parenchymal transection along the paracaval plane. The operative time was 450 min, and the estimated blood loss was 800 ml (no transfusion was required).

CONCLUSION

The laparoscopic Takasaki technique and caudal approach are feasible procedures in the setting of cirrhosis, resulting in an oncologic adequate intervention with less morbidity.

Progress in surgical and nonsurgical approaches for hepatocellular carcinoma treatment

BACKGROUND

Hepatocellular carcinoma (HCC) is a complex and heterogeneous malignancy, frequently occurs in the setting of a chronically diseased organ, with multiple confounding factors making its management challenging. HCC represents one of the leading causes of cancer-related mortality globally with a rising trend of incidence in some of the developed countries, which indicates the need for better surgical and nonsurgical management strategies.

DATA SOURCES

PubMed database was searched for relevant articles in English on the issue of HCC management.

RESULTS

Surgical resection represents a potentially curative option for appropriate candidates with tumors detected at earlier stages and with well-preserved liver function. The long-term outcome of surgery is impaired by a high rate of recurrence. Surgical approaches are being challenged by local ablative therapies such as radiofrequency ablation and microwave ablation in selected patients. Liver transplantation offers potential cure for HCC and also correction of underlying liver disease, and minimizes the risk of recurrence, but is reserved for patients within a set of criteria proposed for a prudent allocation in the shortage of donor organs. Transcatheter locoregional therapies have become the palliative standard allowing local control for intermediate stage patients with noninvasive multinodular or large HCC who are beyond the potentially curative options. The significant survival benefit with the multikinase inhibitor sorafenib for advanced HCC has shifted the direction of research regarding systemic treatment toward molecular therapies targeting the disregulated pathways of hepatocarcinogenesis. Potential benefit is suggested from simultaneous or sequential multimodal therapies, and optimal combinations are being investigated. Despite the striking progress in preclinical studies of HCC immunotherapy and gene therapy, extensive clinical trials are required to achieve successful clinical applications of these innovative approaches.

CONCLUSION

Treatment decisions have become increasingly complex for HCC with the availability of multiple surgical and nonsurgical therapeutic options and require a comprehensive, multidisciplinary approach.

Laparoscopic liver resection: Experience based guidelines

Laparoscopic liver resection (LLR) has been progressively developed along the past two decades. Despite initial skepticism, improved operative results made laparoscopic approach incorporated to surgical practice and operations increased in frequency and complexity. Evidence supporting LLR comes from case-series, comparative studies and meta-analysis. Despite lack of level 1 evidence, the body of literature is stronger and existing data confirms the safety, feasibility and benefits of laparoscopic approach when compared to open resection. Indications for LLR do not differ from those for open surgery. They include benign and malignant (both primary and metastatic) tumors and living donor liver harvesting. Currently, resection of lesions located on anterolateral segments and left lateral sectionectomy are performed systematically by laparoscopy in hepatobiliary specialized centers. Resection of lesions located on posterosuperior segments (1, 4a, 7, 8) and major liver resections were shown to be feasible but remain technically demanding procedures, which should be reserved to experienced surgeons. Hand-assisted and laparoscopy-assisted procedures appeared to increase the indications of minimally invasive liver surgery and are useful strategies applied to difficult and major resections. LLR proved to be safe for malignant lesions and offers some short-term advantages over open resection. Oncological results including resection margin status and long-term survival were not inferior to open resection. At present, surgical community expects high quality studies to base the already perceived better outcomes achieved by laparoscopy in major centers’ practice. Continuous surgical training, as well as new technologies should augment the application of laparoscopic liver surgery. Future applicability of new technologies such as robot assistance and image-guided surgery is still under investigation.

Laparoscopic surgery: A qualified systematic review

AIM: To review current applications of the laparoscopic surgery while highlighting the standard procedures across different fields.

METHODS: A comprehensive search was undertaken using the PubMed Advanced Search Builder. A total of 321 articles were found in this search. The following criteria had to be met for the publication to be selected: Review article, randomized controlled trials, or meta-analyses discussing the subject of laparoscopic surgery. In addition, publications were hand-searched in the Cochrane database and the high-impact journals. A total of 82 of the findings were included according to matching the inclusion criteria. Overall, 403 full-text articles were reviewed. Of these, 218 were excluded due to not matching the inclusion criteria.

RESULTS: A total of 185 relevant articles were identified matching the search criteria for an overview of the current literature on the laparoscopic surgery. Articles covered the period from the first laparoscopic application through its tremendous advancement over the last several years. Overall, the biggest advantage of the procedure has been minimizing trauma to the abdominal wall compared with open surgery. In the case of cholecystectomy, fundoplication, and adrenalectomy, the procedure has become the gold standard without being proven as a superior technique over the open surgery in randomized controlled trials. Faster recovery, reduced hospital stay, and a quicker return to normal activities are the most evident advantages of the laparoscopic surgery. Positive outcomes, efficiency, a lower rate of wound infections, and reduction in the perioperative morbidity of minimally invasive procedures have been shown in most indications.

CONCLUSION: Improvements in surgical training and developments in instruments, imaging, and surgical techniques have greatly increased safety and feasibility of the laparoscopic surgical procedures.

Laparoscopic versus open hepatic resection for hepatocellular carcinoma: improvement in outcomes and similar cost

OBJECTIVE

To compare outcomes of laparoscopic versus open hepatic resection (OHR) exclusively for hepatocellular carcinoma in terms of morbidity and cost.

BACKGROUND

Laparoscopic hepatic resection (LHR) has become more prevalent with recent improvements in instrumentation and surgeon experience.

METHODS

A review of multicenter, prospectively collected hepatobiliary databases from three institutions was performed from 12/1990 to 12/2009. Prospective evaluation of all patients undergoing hepatectomy for hepatocellular cancer was performed.

RESULTS

A total of 354 patients who had resections for Hepatocellular carcinoma (HCC) were analyzed, 100 were performed laparoscopically. The two groups were similar in terms of demographics and comorbidities. Evaluation of outcomes showed significantly higher intraoperative estimated blood loss although postoperative transfusion rates were similar. The incidence of any complication (44 vs 44%, p = 0.23) and 90-day mortality (6 vs 6%, p = 0.8) were similar between the two groups, with a similar reoperation rate (4.0 vs. 2.4%; p = 0.9). Using Cox regression analysis, the laparoscopic approach had no effect on disease-free interval (OR 1.4, CI 0.31-6.3, p = 0.66) or overall survival (HR 1.2, CI 0.59-2.5 p = 0.6). Length of stay was significantly shorter in the laparoscopic group 6.2 vs. 9.3 days (p = 0.001). Adjusted operative charges ($41 vs. $39 k, p = 0.601) and adjusted total hospital charges ($71 vs. $82 k, p = 0.368) were similar in LHR versus OHR.

CONCLUSION

Our study confirms previous literature showing comparable perioperative outcomes and recurrence. We further show comparable cost with laparoscopic versus open liver resection for HCC.

Surgical outcomes after laparoscopic or robotic liver resection in hepatocellular carcinoma: a propensity-score matched analysis with conventional open liver resection

BACKGROUND

This study was designed to compare perioperative and oncologic outcomes between minimally invasive liver resection (MILR) and conventional open liver resection (COLR) for hepatocellular carcinoma (HCC) using a propensity-score matched analysis.

METHODS

Ninety-nine patients who received MILR were matched with 198 patients treated with COLR out of 928 patients with HCC who received curative liver resection from 2002 to 2012. A multivariable logistic model based on factors related to the patient, tumor, and surgical procedure was used to estimate a propensity score.

RESULTS

The MILR group experienced significantly less intraoperative blood loss (mean: 389.55 vs 580.66 mL; P = 0.008), lower complication rates (13.1% vs 24.7%; P = 0.020), and a shorter length of hospital stay (mean: 8.40 vs 13.39 days; P < 0.001). The two groups did not differ significantly in disease-free (P = 0.701) or overall survival (P = 0.086).

CONCLUSIONS

MILR produced better perioperative and comparable oncologic outcomes than COLR for HCC. Copyright © 2015 John Wiley & Sons, Ltd.

Hepatocellular carcinoma: From clinical practice to evidence-based treatment protocols

Hepatocellular carcinoma (HCC) is one of the major malignant diseases in many healthcare systems. The growing number of new cases diagnosed each year is nearly equal to the number of deaths from this cancer. Worldwide, HCC is a leading cause of cancer-related deaths, as it is the fifth most common cancer and the third most important cause of cancer related death in men. Among various risk factors the two are prevailing: viral hepatitis, namely chronic hepatitis C virus is a well-established risk factor contributing to the rising incidence of HCC. The epidemic of obesity and the metabolic syndrome, not only in the United States but also in Asia, tend to become the leading cause of the long-term rise in the HCC incidence. Today, the diagnosis of HCC is established within the national surveillance programs in developed countries while the diagnosis of symptomatic, advanced stage disease still remains the characteristic of underdeveloped countries. Although many different staging systems have been developed and evaluated the Barcelona-Clinic Liver Cancer staging system has emerged as the most useful to guide HCC treatment. Treatment allocation should be decided by a multidisciplinary board involving hepatologists, pathologists, radiologists, liver surgeons and oncologists guided by personalized -based medicine. This approach is important not only to balance between different oncologic treatments strategies but also due to the complexity of the disease (chronic liver disease and the cancer) and due to the large number of potentially efficient therapies. Careful patient selection and a tailored treatment modality for every patient, either potentially curative (surgical treatment and tumor ablation) or palliative (transarterial therapy, radioembolization and medical treatment, i.e., sorafenib) is mandatory to achieve the best treatment outcome.

Perspective of laparoscopic liver resection for hepatocellular carcinoma

Liver resection (LR) for hepatocellular carcinoma (HCC) in patients with chronic liver disease (CLD) is associated with high risks of developing significant postoperative complications and multicentric metachronous lesions, which can result in the need for repeated treatments. Studies comparing laparoscopic procedures to open LR consistently report reduced blood loss and transfusions requirements, lower postoperative morbidity, and shorter hospital stays, with no differences in oncologic outcomes. In addition, laparoscopic LR is associated with reduced postoperative ascites and a lower incidence of liver failure for HCC patients with CLD, due to the reduced surgery-induced parenchymal injury to the residual liver and limited destruction of the collateral blood/lymphatic flow around the liver. Finally, this procedure facilitates subsequent repeat LR due to minimal adhesion formation and improved vision/manipulation between adhesions. These characteristics of laparoscopic LR may lead to an expansion of the indications for LR. This editorial is based on the review and meta-analysis presented at the 2^nd International Consensus Conference on Laparoscopic Liver Resection in Iwate, Japan, in October 2014 (Chairperson of the congress is Professor Go Wakabayashi from the Department of Surgery, Iwate Medical University School of Medicine), which is published in the Journal of Hepato-Biliary-Pancreatic Sciences.

Outcomes of robotic vs laparoscopic hepatectomy: A systematic review and meta-analysis

AIM: To perform a systematic review and meta-analysis on robotic-assisted vs laparoscopic liver resections.

METHODS: A systematic literature search was performed using PubMed, Scopus and the Cochrane Library Central. Participants of any age and sex, who underwent robotic or laparoscopic liver resection were considered following these criteria: (1) studies comparing robotic and laparoscopic liver resection; (2) studies reporting at least one perioperative outcome; and (3) if more than one study was reported by the same institute, only the most recent was included. The primary outcome measures were set for estimated blood loss, operative time, conversion rate, R1 resection rate, morbidity and mortality rates, hospital stay and major hepatectomy rates.

RESULTS: A total of 7 articles, published between 2010 and 2014, fulfilled the selection criteria. The laparoscopic approach was associated with a significant reduction in blood loss and lower operative time (MD = 83.96, 95%CI: 10.51-157.41, P = 0.03; MD = 68.43, 95%CI: 39.22-97.65, P < 0.00001, respectively). No differences were found with respect to conversion rate, R1 resection rate, morbidity and hospital stay.

CONCLUSION: Laparoscopic liver resection resulted in reduced blood loss and shorter surgical times compared to robotic liver resections. There was no difference in conversion rate, R1 resection rate, morbidity and length of postoperative stay.

Long-term and perioperative outcomes of laparoscopic versus open liver resection for hepatocellular carcinoma with propensity score matching: a multi-institutional Japanese study

BACKGROUND

The aim of this study was to compare the long-term outcomes and perioperative outcomes of laparoscopic liver resection (LLR) with those of open liver resection (OLR) for hepatocellular carcinoma (HCC) between well-matched patient groups.

METHODS

Hepatocellular carcinoma patients underwent primary liver resection between 2000 and 2010, were collected from 31 participating institutions in Japan and were divided into LLR (n = 436) and OLR (n = 2969) groups. A one-to-one propensity case-matched analysis was used with covariates of baseline characteristics, including tumor characteristics and surgical procedures of hepatic resections. Long-term and short-term outcomes were compared between the matched two groups.

RESULTS

The two groups were well balanced by propensity score matching and 387 patients were matched. There were no significant differences in overall survival and disease-free survival between LLR and OLR. The median blood loss (158 g vs. 400 g, P < 0.001) was significantly less with LLR, and the median postoperative hospital stay (13 days vs. 16 days, P < 0.001) was significantly shorter for LLR. Complication rate (6.7% vs. 13.0%, P = 0.003) was significantly less in LLR.

CONCLUSION

Compared with OLR, LLR in selected patients with HCC showed similar long-term outcomes, associated with less blood loss, shorter hospital stay, and fewer postoperative complications.

Liver resection for hepatocellular carcinoma in 313 Western patients: tumor biology and underlying liver rather than tumor size drive prognosis

BACKGROUND & AIMS

Treatment decisions for hepatocellular carcinoma are mostly guided by tumor size. The aim of this study was to analyze resection outcomes according to tumor size and characterize prognostic factors.

METHODS

Patients resected at a Western center between 1989 and 2010 were grouped by largest tumor size: <50mm, 50-100mm, and >100mm. The primary end points were overall- and recurrence-free survival. Univariate associations with primary endpoints were entered into a Cox proportional hazard regression model.

RESULTS

Three hundred thirteen patients underwent resection: 111 (36%) had tumors <50mm, 113 (36%) had tumors between 50 and 100mm, and 89 (28%) had tumors >100mm. Five-year overall and disease-free survival rates for the three groups were 67%, 46%, and 34%, and 32%, 27%, and 27%, respectively. Thirty-five patients, mostly from <50mm group, underwent transplantation which was associated with a 91% 5 year survival rate. Tumor size was not an independent predictor of overall or recurrence-free survival on multivariate analyses. Independent predictors of decreased overall survival were: intraoperative transfusion (HR=2.60), cirrhosis (HR=2.42), poorly differentiated tumor (HR=2.04), satellite lesions (HR=1.69), alpha-fetoprotein >200 (HR=1.53), and microvascular invasion (HR=1.48). The use of salvage transplantation was an independent predictor of improved survival (HR=0.21). Recurrence-free survival was predicted by intraoperative transfusion (HR=2.15), poorly differentiated tumor (HR=1.87), microvascular invasion (HR=1.71) and cirrhosis (HR=1.69).

CONCLUSION

By studying a large group of patients across a distribution of tumor sizes and background liver diseases, it is demonstrated that size alone is a limited prognostic factor. Tumor biology and condition of the underlying liver are better prognosticators and should be given closer attention. Although hampered by recurrence rates, resection is safe and offers good overall survival. In addition, it may allow for better selection for salvage transplantation after consideration of histopathological risk factors.

Recent advances in multidisciplinary management of hepatocellular carcinoma

The incidence of hepatocellular carcinoma (HCC) is increasing, and it is currently the second leading cause of cancer-related death worldwide. Potentially curative treatment options for HCC include resection, transplantation, and percutaneous ablation, whereas palliative treatments include trans-arterial chemoembolization (TACE), radioembolization, and systemic treatments. Due to the diversity of available treatment options and patients' presentations, a multidisciplinary team should decide clinical management of HCC, according to tumor characteristics and stage of liver disease. Potentially curative treatments are suitable for very-early- and early-stage HCC. However, the vast majority of HCC patients are diagnosed in later stages, where the tumor characteristics or progress of liver disease prevent curative interventions. For patients with intermediate-stage HCC, TACE and radioembolization improve survival and are being evaluated in addition to potentially curative therapies or with systemic targeted therapy. There is currently no effective systemic chemotherapy, immunologic, or hormonal therapy for HCC, and sorafenib is the only approved molecular-targeted treatment for advanced HCC. Other targeted agents are under investigation; trials comparing new agents in combination with sorafenib are ongoing. Combinations of systemic targeted therapies with local treatments are being evaluated for further improvements in HCC patient outcomes. This article provides an updated and comprehensive overview of the current standards and trends in the treatment of HCC.

Current management of hepatocellular carcinoma: an Eastern perspective

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer death, especially in Eastern areas. With advancements in diagnosis and treatment modalities for HCC, the survival and prognosis of HCC patients are improving. However, treatment patterns are not uniform between areas despite efforts to promote a common protocol. Although many hepatologists in Asian countries may adopt the principles of the Barcelona Clinic Liver Cancer staging system, they are also independently making an effort to expand the indications of each treatment and to combine therapies for better outcomes. Several expanded criteria for liver transplantation in HCC have been developed in Asian countries. Living donor liver transplantation is much more commonly performed in these countries than deceased donor liver transplantation, and it may be preceded by other treatments such as the down-staging of tumors. Local ablation therapies are often combined with transarterial chemoembolization (TACE) and the outcome is comparable to that of surgical resection. The indications of TACE are expanding, and there are new types of transarterial therapies. Although data on drug-eluting beads, TACE, and radioembolization in Asian countries are still relatively sparse compared with Western countries, these methods are gradually gaining popularity because of better tolerability and the possibility of improved response rates. Hepatic arterial infusion chemotherapy and radiotherapy are not included in Western guidelines, but are currently being used actively in several Asian countries. For more advanced HCCs, appropriate combinations of TACE, radiotherapy, and sorafenib can be considered, and emerging data indicate improved outcomes of combination therapies compared with single therapies. To include these paradigm shifts into newer treatment guidelines, more studies may be needed, but they are certainly in progress.

Can we expand the indications for laparoscopic liver resection? A systematic review and meta-analysis of laparoscopic liver resection for patients with hepatocellular carcinoma and chronic liver disease

Liver resection (LR) for patients with hepatocellular carcinoma (HCC) and chronic liver disease (CLD) poses a high risk of serious postoperative complications and multicentric metachronous lesions requiring repeated treatment. The efficacy of laparoscopic LR (LLR) for such patients has yet to be established. The objective of this study is to test the outcomes of LLR for HCC with the aim of considering potential expansion of the indications for LLR. We performed a systematic review of the pertinent English-language literature. Our search yielded four meta-analyses and 23 comparative studies of LLR for HCC. On the basis of the findings from these studies and our newly conducted meta-analysis, the possibility for expanding the indications for LLR to HCC was examined. The studies show that LLR (vs open) for HCC generally yields better short-term outcomes without compromising long-term outcomes, and that incidences of postoperative ascites and liver failure are decreased with LLR. Several studies show the benefits of LLR for patients with severe CLD and for repeat surgery. Reductions of postoperative ascites and liver failure are among the advantages of LLR. These characteristics of LLR may allow us to expand the indications of LLR to HCC with CLD.

Bleeding control during laparoscopic liver resection: a review of literature

Despite the established advantages of laparoscopy, bleeding control during laparoscopic liver resection (LLR) is a liver-specific improvement. The 2nd International Consensus Conference on Laparoscopic Liver Resection was held in October 2014 at Morioka, Japan. One of the most capital questions was: What is essential in bleeding control during LLR? In order to correctly address this question, we conducted a comprehensive review of the literature. Essential points based on personal experience of the expert panel are also discussed. A total of 54 publications were identified. Based on this analysis, the working group built these recommendations: (1) a pneumoperitoneum of 10-14 mmHg should be used as it allows a good control of the bleeding without significant modifications of hemodynamics; (2) a low central venous pressure (<5 mmHg) should be used; (3) laparoscopy facilitates inflow and outflow control; and (4) surgeons should be experienced with the use of all surgical devices for liver transection and should master laparoscopic suture before starting LLR. Precoagulation with radiofrequency can be useful, particularly in cases of atypical resection. These recommendations are mostly based on experts' opinions and on B or C quality of evidence grade studies. More prospective data are required to confirm these results.

Short-term administration of steroids does not affect postoperative complications following liver resection: Evidence from a meta-analysis of randomized controlled trials

AIM

Although perioperative short-term administration of steroids can attenuate surgical stress response following liver resection, there is no consensus concerning the effect on postoperative complications. This study aims to use meta-analysis to quantitatively investigate the effect of perioperative short-term administration of steroids on postoperative complications following liver resection.

METHODS

A systematic published work search was performed to detect randomized controlled trials (RCT) assessing the effect of perioperative short-term administration of steroids on outcomes following liver resection. Parameters of surgical stress, hospital stay and postoperative complications were analyzed. Two authors independently assessed study quality and extracted data. All data were analyzed using RevMan version 5 and meta-analyses were performed using a random-effects model.

RESULTS

Five RCT published between 2001 and 2011 containing a total of 379 patients were eligible for final analysis. Serum total bilirubin, interleukin-6 and C-reactive protein were significantly lower in the steroid than in the control group on postoperative day 1 (P = 0.02, 0.004 and 0.02, respectively). There was no difference in duration of hospital stay between the steroid and control group (P = 0.37). The analysis of end-points including infective complications (odds ratio [OR], 0.95), wound complications (OR, 0.67), bile leakage (OR, 0.58) and overall complications (OR, 0.50) revealed no difference between steroid administration and no treatment. There was no postoperative death or adverse effect attributable to steroid treatment in all patients.

CONCLUSION

On currently available evidence, short-term administration of steroids does not increase incidence of complications in patients undergoing liver resection.

Laparoscopic versus open liver resection for metastatic colorectal cancer: a metaanalysis of 610 patients

BACKGROUND

Laparoscopic liver resection (LLR) for metastatic colorectal cancer (mCRC) remains controversial. The objective of this manuscript was to perform a metaanalysis comparing outcomes of LLR with open liver resection (OLR) in patients with hepatic mCRC, and to identify which patients were suitable candidates for LLR.

STUDY DESIGN

A PubMed search identified 2,122 articles. When filtered for case-matched articles comparing LLR with OLR for mCRC, 8 articles were identified consisting of 610 patients (242 LLR, 368 OLR). A random effects metaanalysis was performed.

RESULTS

The 2 groups were well-matched for age, sex, American Society of Anesthesiologists score, tumor size, number of metastases, extent of major hepatectomy, and use of neoadjuvant/adjuvant chemotherapy. The mean number of metastases in the LLR and OLR groups were 1.4 and 1.5, respectively (P = .14). Estimated blood loss was less in LLR group (262 vs 385 mL; P = .049). Transfusion rate was significantly less in LLR group (9.9 vs 19.8%; P = .004). There was no difference in operative time (248.7 vs 262.8 min; P = .85). Length of stay (LOS) was less in the LLR group (6.5 vs 8.8 days; P = .007). The overall complication rate was less in LLR group (20.3% vs 33.2%; P = .03). Importantly, there was no difference in the 1-, 3-, and 5-year disease-free survival (DFS) or overall survival (OS) rates.

CONCLUSION

In carefully selected patients with limited mCRC (1 or 2 tumors), LLR provides marked perioperative benefits without compromising oncologic outcomes or long-term survival. Specifically, LLR offers decreased blood loss, LOS, and overall complication rates with comparable 5-year OS and DFS.

Long-term favorable surgical results of laparoscopic hepatic resection for hepatocellular carcinoma in patients with cirrhosis: a single-center experience over a 10-year period

BACKGROUND

We first performed laparoscopic hepatic resection (Lap-Hx) for hepatocellular carcinoma (HCC) in 1994. Here we review the long-term surgical results of Lap-Hx for HCC in patients with cirrhosis over a 10-year period at a single institution.

STUDY DESIGN

Between January 2000 and December 2013, 99 patients with cirrhosis underwent open hepatic resection (Open-Hx) and 63 underwent Lap-Hx for primary HCC within the Milan criteria. We compared the operative outcomes and patient survival between the 2 groups.

RESULTS

There were no significant differences regarding patient background characteristics or tumor-related factors between the 2 groups. The morbidity rate of the Lap-Hx group was significantly lower than that of the Open-Hx group (26% vs 10%; p = 0.0459), and the complication rate of ascites was significantly lower (7% vs 0%; p = 0.0077). The mean duration of hospital stay of the Lap-Hx group was significantly shorter than that of the Open-Hx group (16 vs 10 days; p = 0.0008). There were no significant between-group differences regarding overall or disease-free survival.

CONCLUSIONS

Laparoscopic-Hx for HCC in patients with cirrhosis is associated with less morbidity and shorter hospital stays, with no compromise in patient survival. It may be time to consider changing the standard operation for primary HCC within the Milan criteria to Lap-Hx in patients with cirrhosis.

[Laparoscopic liver surgery]

Liver resection remains the method of choice for curative treatment for liver tumors. Development in diagnostic and surgical techniques has improved operative results as well as long-term outcomes. In the last decade minimally invasive laparoscopic (LAP) surgery has been increasingly adopted by liver units. The trend in LAP liver resection has been moving from limited resections towards major hepatectomy. This process, however, is relatively slow, which can be due to technical difficulties of the procedure and fear of haemorrhage. Despite having a hard time at the start, major resections become more common. Up to now approximately 6000 LAP liver resections were performed worldwide, number of major hepatectomies is estimated between 700-800. LAP liver resections are feasible with significant benefits for patients consisting of less blood loss, less narcotic requirements, and shorter hospital stay with comparable postoperative morbidity and mortality to open liver resections. It is an accepted management of both benign and malignant liver lesions. There is no difference between LAP and open surgery in late survival after resection for colorectal liver metastases. Overall survival of LAP resected hepatocellular carcinoma cases seems to be superior compared with open surgery.