Role and limitations of laparoscopic liver resection of colorectal metastases

Laparoscopic Versus Open Liver Resection for Colorectal Liver Metastases: A Comprehensive Systematic Review and Meta-analysis

The effects of laparoscopic liver resection (LLR) and open liver resection (OLR) on oncological outcomes for colorectal cancer liver metastases (CCLM) remain inconclusive. Major databases were searched from January 1992 to October 2016. Effects of LLR vs OLR were determined. The primary endpoints were oncological outcomes. In total, 32 eligible non-randomized studies with 4697 patients (LLR: 1809, OLR: 2888) were analyzed. There were higher rates of clear surgical margins (OR: 1.64, 95%CI: 1.32 to 2.05, p < 0.00001) in the LLR group, without significant differences in disease recurrence, 3- or 5-year overall survival(OS) and disease free survival(DFS) between the two approaches. LLR was associated with less intraoperative blood loss (WMD: −147.46 [−195.78 to −99.15] mL, P < 0.00001) and fewer blood transfusions (OR: 0.41 [0.30–0.58], P < 0.00001), but with longer operation time (WMD:14.44 [1.01 to 27.88] min, P < 0.00001) compared to OLR. Less overall morbidity (OR: 0.64 [0.55 to 0.75], p < 0.00001) and shorter postoperative hospital stay (WMD: −2.36 [−3.06 to −1.66] d, p < 0.00001) were observed for patients undergoing LLR, while there was no statistical difference in mortality. LLR appears to be a safe and feasible alternative to OLR in the treatment of CCLM in selected patients.

Modified hepatic vascular occlusion facilitates hepatectomy for malignant hepatic tumor in laparoscopy

PURPOSE

The parenchymal transection and bleeding are important problems in laparoscopic hepatectomy (LH). The study aimed to evaluate the feasibility and safety of LH for a malignant hepatic tumor (MHT) with hepatic vascular occlusion (HVO) only using a monopolar electrocautery.

METHODS

A total of 31 patients' profiles, operative data, clinical outcomes, pathologic findings, and follow-up information were collected who underwent LH with HVO.

RESULTS

The median operative time was 176 minutes and the median postoperative hospital stay was 9 days. The median estimated blood loss was 310 mL. The median tumor size was 4.6 cm and the median surgical margin was 12 mm.The ischemia injury to the liver in patients subjected to selective HVO was less than that in patients subjected to the Pringle maneuver.

CONCLUSIONS

HVO facilitates LH in transecting liver parenchyma and reduces bleeding, making LH safe and feasible only using monopolar electrocautery in selected patients with malignancies. Moreover, the selective HVO have more advantages over the Pringle maneuver in decreasing ischemic injury.

Starting a new laparoscopic liver surgery program: initial experience and improved efficiency

BACKGROUND

Owing to the anatomic complexity of the liver and the risk of hemorrhage, most liver resections are still performed using an open procedure. We evaluated the outcomes of introducing a laparoscopic liver program to a community teaching hospital.

METHODS

We retrospectively reviewed laparoscopic liver resections performed between August 2010 and July 2013 at St. Joseph's Health Centre in Toronto. The primary outcomes were mortality, major morbidity and negative margins. Secondary outcomes included other perioperative outcomes. We used nonparametric tests to compare the outcomes during the first (group A) and second (group B) halves of the study period.

RESULTS

Group A included 19 patients and group B had 25 patients; 9 and 4 patients, respectively, had major resections. Group A had the only death due to liver failure. There was no difference in major complications (10.6% v. 16%) or length of stay (4.5 v. 4.6 d) between the groups. One patient in group B had a positive margin. There was a significant decrease in duration of surgery (from 237 to 170 min, p = 0.007), with a trend toward shorter duration for major resections (from 318 to 238 min, p = 0.07). Furthermore, more procedures were performed for malignancy in group B than group A (36.8% v. 84.0%, p = 0.001).

CONCLUSION

Laparoscopic liver resection can be safely introduced into a Canadian community teaching hospital. Average duration of surgery decreased by 67 minutes despite a 2-fold increase in the number of cases performed for malignancy.

Margin status after laparoscopic resection of colorectal liver metastases: does a narrow resection margin have an influence on survival and local recurrence?

OBJECTIVES

Recent studies of margin-related recurrence have raised questions on the necessity of ensuring wide resection margins in the resection of colorectal liver metastases. The aim of the current study was to determine whether resection margins of 10 mm provide a survival benefit over narrower resection margins.

METHODS

A total of 425 laparoscopic liver resections were carried out in 351 procedures performed in 317 patients between August 1998 and April 2012. Primary laparoscopic liver resections for colorectal metastases were included in the study. Two-stage resections, procedures accompanied by concomitant liver ablations and one case of perioperative mortality were excluded. A total of 155 eligible patients were classified into four groups according to resection margin width: Group 1, margins of < 1 mm [n = 33, including 17 patients with positive margins (Group 1a)]; Group 2, margins of 1 mm to < 3 mm (n = 31); Group 3, margins of ≥ 3 mm to <10 mm (n = 55), and Group 4, margins of ≥ 10 mm (n = 36). Perioperative and survival data were compared across the groups. Median follow-up was 31 months (range: 2-136 months).

RESULTS

Perioperative outcomes were similar in all groups. Unfavourable intraoperative incidents occurred in 9.7% of procedures (including 3.2% of conversions). Postoperative complications developed in 11.0% of patients. Recurrence in the resection bed developed in three (1.9%) patients, including two (6.1%) patients in Group 1. Rates of actuarial 5-year overall, disease-free and recurrence-free survival were 49%, 41% and 33%, respectively. Median survival was 65 months. Margin status had no significant impact on patient survival. The Basingstoke Predictive Index (BPI) generally underestimated survival. This underestimation was especially marked in Group 1 when postoperative BPI was applied.

CONCLUSIONS

Patients with margins of <1 mm achieved survival comparable with that in patients with margins of ≥ 10 mm. When modern surgical equipment that generates an additional coagulation zone is applied, the association between resection margin and survival may not be apparent. Further studies in this field are required. Postoperative BPI, which includes margin status among the core factors predicting postoperative survival, seems to be less precise than preoperative BPI.

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.

Liver resection for hepatocellular carcinoma: case-matched analysis of laparoscopic versus open resection

Purpose

To analyze the outcomes of laparoscopic liver resection compared with open liver resection in patients with hepatocellular carcinoma (HCC).

Methods

Between July 2005 and December 2009, 26 consecutive patients with HCC underwent a pure laparoscopic liver resection, and data from this group (laparoscopic liver resection group, L-group) were compared with a retrospective control group of 29 patients who underwent open liver resection for HCC (open liver resection group, O-group) during the same period. The two groups were matched in terms of demographic data, tumor size, degree of liver cirrhosis, American Society of Anesthesiology score, type of resection, and tumor location.

Results

Median operation time and the amount of intraoperative packed red blood cell transfusion in the L-group were 147.5 minutes and 0.35 units, respectively. The L-group revealed a shorter operation time (147.5 vs. 220.0 minutes, P = 0.031) than the O-group. No difference in perioperative morbidity or mortality rates was observed (3.8, 0 vs. 24.1%, 0%; P = 0.054, non-specific, respectively); the L-group was associated with a shorter hospital stay than the O-group (11.08 vs. 16.07 days, P = 0.034). After a mean follow-up of 23.9 months (range, 0.7 to 59.4 months), the 1-year disease-free survival rate was 84.6% in the L-group and 82.8% in the O-group (P = 0.673).

Conclusion

Laparoscopic liver resection for HCC is feasible and safe in selected patients and can produce good surgical results with a shorter postoperative hospital stay and similar outcomes in terms of perioperative morbidity, mortality, and disease-free survival than open resection.

Laparoscopic hepatectomy: a systematic review, meta-analysis, and power analysis

PURPOSE

A previous meta-analysis study demonstrated that bleeding and the duration of the hospital stay following laparoscopic hepatectomy (Lap) were significantly smaller and shorter, respectively, than for patients undergoing an open approach (Op). The aim of the present study was to re-evaluate perioperative variables and adverse outcomes in patients undergoing Lap versus (vs) Op after 2000.

METHODS

A PubMed and Ovid Medline search identified clinical studies that compared the outcomes of Lap vs Op patients after 2000. A meta-analysis and power analysis were performed.

RESULTS

Operative time was not significantly different between the two approaches (95% confidence interval [CI]: -0.063 to 0.992). Patient bleeding in the Lap group was significantly lower than in the Op group (95% CI: -1.027 to -0.390). Complications with Lap patients were significantly less frequent (95% CI: 0.231-0.642), and the duration of the hospital stay for Lap patients was significantly shorter (95% CI: -0.950 to -0.530) than for Op patients. Only one paper presented 80% power with 0.05 α-errors in all four outcomes, whereas four studies did not have sufficient statistical power.

CONCLUSIONS

The clinical benefits of Lap include a smaller incidence of complications and a shorter duration of hospital stay at the current time. Several studies had too few cases to sufficiently evaluate these factors, although other studies were appropriately analyzed.

Lessons from laparoscopic liver surgery: a nine-year case series

Objective. This series describes a developing experience in laparoscopic liver surgery presenting results from 40 procedures including right hemihepatectomy, left lateral lobectomy, and microwave ablation therapy. Methods. Forty patients undergoing laparoscopic liver surgery between September 1997 and November 2006 were included. The data set includes: operative procedure and duration, intraoperative blood loss, conversion to open operation rates, length of hospital stay, complications, mortality, histology of lesions/resection margins, and disease recurrence. Results. Mean age of patient: 59 years, 17/40 male, 23/40 female, 23/40 of lesions were benign, and 17/40 malignant. Operations included: laparoscopic anatomical resections n = 15, nonanatomical resections n = 11, microwave ablations n = 8 and deroofing of cysts n = 7. Median anaesthetic time: 120 minutes (range 40–240), mean blood loss 78 mL and 1/40 conversions to open. Median resection margins were 10 mm (range 1–14) and median length of stay 3 days (range 1–10). Operative and 30-day mortality were zero with no local disease recurrence. Conclusion. Laparoscopic liver surgery appears safe and effective and is associated with reduced hospital stay. Larger studies are required to confirm it is oncologically sound.

Open liver resection for colorectal metastases: better short- and long-term outcomes in patients potentially suitable for laparoscopic liver resection

BACKGROUND

There is no prospective randomized data comparing laparoscopic to open hepatectomy. This study compared short- and long-term outcomes in patients undergoing hepatectomy for colorectal metastases (CRM), who were suitable for either laparoscopic or open surgery.

METHODS

Data were prospectively collected from consecutive patients undergoing hepatic resection of CRM at a single centre (1987-2007). Patients who were suitable for laparoscopic resection (Group 1) were compared with patients whose tumour characteristics would best be considered for open resection (Group 2).

RESULTS

Out of 1152 hepatectomies, 266 (23.1%) were deemed suitable for a laparoscopic approach. The median (IQR) number of metastases was greater in Group 2 [2(1-20) vs. 1(1-10), P < 0.001], as was the mean (SD) tumour size [5.3(3.6) cm vs. 3.3(1.2) cm, P < 0.001]. The median (IQR) operation time [210 (70) min vs. 240 (90) min, P < 0.001] and blood loss [270 (265) ml vs. 355 (320) ml, P < 0.001] were less in Group 1. There was no difference in length of stay, morbidity or mortality. Patients in Group 2 had a higher R1 resection rate (14.9%) compared with Group 1 (4.5%, P < 0.001) and lower 5-year survival (37.8% vs. 44.2%, P= 0.005).

DISCUSSION

Current criteria for laparoscopic hepatectomy selects patients who have more straight-forward surgery, with less risk of an involved resection margin and better long-term survival, compared with patients unsuited to a laparoscopic approach. Clearly defined criteria for laparoscopic hepatectomy are essential to allow meaningful analysis of outcomes and the results of unrandomized series of laparoscopic hepatectomies must be interpreted with caution.

World review of laparoscopic liver resection-2,804 patients

OBJECTIVE

To provide a review of the world literature on laparoscopic liver resection.

SUMMARY BACKGROUND DATA

Initially described for peripheral, benign tumors resected by nonanatomic wedge resections, minimally invasive liver resections are now being performed more frequently, even for larger, malignant tumors located in challenging locations. Although a few small review articles have been reported, a comprehensive review on laparoscopic liver resection has not been published.

METHODS

We conducted a literature search using Pubmed, screening all English publications on laparoscopic liver resections. All data were analyzed and apparent case duplications in updated series were excluded from the total number of patients. Tumor type, operative characteristics, perioperative morbidity, and oncologic outcomes were tabulated.

RESULTS

A total of 127 published articles of original series on laparoscopic liver resection were identified, and accounted for 2,804 reported minimally invasive liver resections. Fifty percent were for malignant tumors, 45% were for benign lesions, 1.7% were for live donor hepatectomies, and the rest were indeterminate. Of the resections, 75% were performed totally laparoscopically, 17% were hand-assisted, and 2% were laparoscopic-assisted open hepatic resection (hybrid) technique, with the remainder being other techniques or conversions to open hepatectomies. The most common laparoscopic liver resection was a wedge resection or segmentectomy (45%) followed by anatomic left lateral sectionectomy (20%), right hepatectomy (9%), and left hepatectomy (7%). Conversion from laparoscopy to open laparotomy and from laparoscopy to hand-assisted approach occurred in 4.1% and 0.7% of reported cases, respectively. Overall mortality was 9 of 2,804 patients (0.3%), and morbidity was 10.5%, with no intraoperative deaths reported. The most common cause of postoperative death was liver failure. Postoperative bile leak was observed in 1.5% of cases. For cancer resections, negative surgical margins were achieved in 82% to 100% of reported series. The 5-year overall and disease-free survival rates after laparoscopic liver resection for hepatocellular carcinoma were 50% to 75% and 31% to 38.2%, respectively. The 3-year overall and disease-free survival rates after laparoscopic liver resection for colorectal metastasis to the liver were 80% to 87% and 51%, respectively.

CONCLUSION

In experienced hands, laparoscopic liver resections are safe with acceptable morbidity and mortality for both minor and major hepatic resections. Oncologically, 3- and 5-year survival rates reported for hepatocellular carcinoma and colorectal cancer metastases are comparable to open hepatic resection, albeit in a selected group of patients.

Laparoscopic liver surgery

Great advances have occurred in the field of laparoscopic hepatic surgery. It is now clear that in experienced hands, the laparoscopic method of liver resection is as safe as an open procedure. The key phrase in this last sentence is "in experienced hands". The new devices that are available might make an inexperienced hepatic surgeon, well-trained in laparoscopic surgery, embark on hepatic resection without thorough knowledge of hepatic anatomy. The converse may also be true. As no criteria for credentialing of laparoscopic hepatic surgeons exist, the decision as to who is sufficiently trained to perform these procedures is left to individual hospital credentialing boards. While a certification procedure defined by leaders in this field and supported by surgical societies would be welcomed, the ability to achieve and enforce these guidelines appear to be more of a challenge. In addition, while most comparison studies in this area conclude by suggesting that a randomized, clinical trial would be needed to definitively arrive at an answer regarding the benefits of minimally invasive liver surgery compared with open surgery, it would likely be extremely difficult to accrue patients, given the data presented in articles regarding the success of laparoscopic hepatic resections. The authors conclude that an internationalregistry of all laparoscopic cases should b e established to insure patient safety and a mechanism for self-monitoring.

Intraoperative laparoscope augmentation for port placement and resection planning in minimally invasive liver resection

In recent years, an increasing number of liver tumor indications were treated by minimally invasive laparoscopic resection. Besides the restricted view, two major intraoperative issues in laparoscopic liver resection are the optimal planning of ports as well as the enhanced visualization of (hidden) vessels, which supply the tumorous liver segment and thus need to be divided (e.g., clipped) prior to the resection. We propose an intuitive and precise method to plan the placement of ports. Preoperatively, self-adhesive fiducials are affixed to the patient's skin and a computed tomography (CT) data set is acquired while contrasting the liver vessels. Immediately prior to the intervention, the laparoscope is moved around these fiducials, which are automatically reconstructed to register the patient to its preoperative imaging data set. This enables the simulation of a camera flight through the patient's interior along the laparoscope's or instruments' axes to easily validate potential ports. Intraoperatively, surgeons need to update their surgical planning based on actual patient data after organ deformations mainly caused by application of carbon dioxide pneumoperitoneum. Therefore, preoperative imaging data can hardly be used. Instead, we propose to use an optically tracked mobile C-arm providing cone-beam CT imaging capability intraoperatively. After patient positioning, port placement, and carbon dioxide insufflation, the liver vessels are contrasted and a 3-D volume is reconstructed during patient exhalation. Without any further need for patient registration, the reconstructed volume can be directly augmented on the live laparoscope video, since prior calibration enables both the volume and the laparoscope to be positioned and oriented in the tracking coordinate frame. The augmentation provides the surgeon with advanced visual aid for the localization of veins, arteries, and bile ducts to be divided or sealed.

Evaluation of 300 minimally invasive liver resections at a single institution: less is more

OBJECTIVE

We present the largest, most comprehensive, single center experience to date of minimally invasive liver resection (MILR).

SUMMARY BACKGROUND DATA

Despite anecdotal reports of MILR, few large single center reports have examined these procedures by comparing them to their open counterparts.

METHODS

Three hundred MILR were performed between July 2001 and November 2006 at our center for both benign and malignant conditions. These included 241 pure laparoscopic, 32 hand-assisted laparoscopic, and 27 laparoscopy-assisted open (hybrid) resections.These MILR were compared with 100 contemporaneous, cohort-matched open resections. MILR included segmentectomies (110), bisegmentectomies (63), left hepatectomies (47), right hepatectomies (64), extended right hepatectomies (8), and caudate lobe (8) resections. Benign etiologies encompassed cysts (70), hemangiomata (37), focal nodular hyperplasia (FNH) (23), adenomata (47), and 20 live donor right lobectomies. Malignant etiologies included primary (43) and metastatic (60) tumors. Hepatic fibrosis/cirrhosis was present in 25 of 103 patients with malignant diseases (24%).

RESULTS

There was high data consistency within the 3 types of MILR. MILR compared favorably with standard open techniques: operative times (99 vs. 182 minutes), blood loss (102 vs. 325 ml), transfusion requirement (2 of 300 vs. 8 of 100), length of stay (1.9 vs. 5.4 days), overall operative complications (9.3% vs. 22%), and local malignancy recurrence (2% vs. 3%). No port-site recurrences occurred. Conversion from laparoscopic to hand-assisted laparoscopic resection occurred in 20 patients (6%), with no conversions to open. No hand-assisted procedures were converted to open, but 2 laparoscopy-assisted (7%) were converted to open.

CONCLUSION

Our data show that MILR outcomes compare favorably with those of the open standard technique. Our experience suggests that MILR of varying magnitudes is safe and effective for both benign and malignant conditions.

Laparoscopic liver surgery: Shifting the management of liver tumors

Laparoscopic liver surgery has evolved rapidly over the past 5 years in a select number of centers. The growing experience with these procedures has resulted in a shift in the diagnostic and therapeutic approach to common liver tumors. The fact that resection of benign and malignant hepatic masses can now be accomplished laparoscopically with relatively low morbidity has influenced the decision-making process for physicians involved in the diagnosis and management of these lesions. For example, should a gastroenterologist or hepatologist seeing a 32-year-old woman with an asymptomatic 4 cm hepatic lesion that is radiologically indeterminate for adenoma or focal nodular hyperplasia (FNH): (1) continue to observe with annual computed tomography/magnetic resonance imaging (CT/MRI) scans, (2) subject the patient to a liver biopsy, or (3) refer for laparoscopic resection? For a solitary malignant liver tumor in the left lateral segment, should laparoscopic resection be considered the new standard of care, assuming the surgeon can perform the operation safely? We present current data and representative case studies on the use of laparoscopic liver resection at 2 major medical centers in the United States. We propose that surgical engagement defined by the managing physician's decision to proceed with a surgical intervention is increasingly affected by the availability of, and experience with, laparoscopic liver resection.