Outcome for patients treated with laparoscopic versus open resection of hepatocellular carcinoma: case-matched analysis

Open Versus Laparoscopic Right Hepatectomy for Hepatocellular Carcinoma Following Sequential TACE-PVE: A Multicentric Comparative Study

BACKGROUND

Right hepatectomy (RH) for hepatocellular carcinoma (HCC) is ideally preceded by transcatheter arterial chemoembolization (TACE) and portal vein embolization (PVE). Laparoscopic approach improves short-term outcome and textbook outcome (TO), which reflects the "ideal" surgical outcome, after RH. However, laparoscopic RH on an underlying diseased liver and after TACE/PVE remains a challenging procedure. The aim of this study was to compare the outcomes in patients who underwent laparoscopic liver resection (LLR) or open liver resection (OLR) following TACE/PVE.

PATIENTS AND METHODS

All patients with HCC who underwent RH after TACE/PVE in five French centers were retrospectively included. Outcomes were compared between the LLR group and the OLR group using propensity score matching (PSM). Quality of surgical care was defined by TO.

RESULTS

Between 2005 and 2019, 117 patients were included (41 in LLR group, 76 in OLR group). Overall morbidity was comparable (51% versus 53%, p = 0.24). In LLR group, TO was completed in 66% versus 37% in OLR group (p = 0.02). LLR and absence of clamping were the only factors associated with TO completion [hazard ratio (HR) 4.27, [1.77-10.28], p = 0.001]. After PSM, 5-year overall survival (OS) and progression-free survival (PFS) were 55% in matched LLR versus 77% in matched OLR, p = 0.35, and 13% in matched LLR versus 17% in matched OLR, p = 0.97. TO completion was independently associated with a better 5-year OS (65.2% versus 42.5%, p = 0.007).

CONCLUSION

Major LLR after TACE/PVE should be considered as a valuable option in expert centers to increase the chance of TO, the latter being associated with a better 5-year OS.

Laparoscopic Hepatectomy versus Open Hepatectomy After Conversion Therapy Using Transarterial Chemoembolization or Hepatic Arterial Infusion Chemotherapy for Patients with Initially Unresectable Hepatocellular Carcinoma

Background

Laparoscopic hepatectomy (LH) is more advantageous than open hepatectomy (OH) for hepatocellular carcinoma (HCC). However, surgical methods of conversion resection for patients with HCC have not been compared. We aimed to compare LH with OH for HCC after conversion therapy.

Methods

We retrospectively reviewed the data of 334 patients who underwent conversion resection between January 2016 and December 2020 at Sun Yat-sen University, China. Propensity score matching (PSM) of patients in a ratio of 1:2 was conducted, and 62 patients and 121 patients who underwent LH and OH, respectively, were matched.

Results

The LH and OH groups differed at baseline in terms of ALT (P=0.008), AFP (P=0.042), largest tumor size (P=0.028), macrovascular invasion (P=0.006), BCLC stages (P=0.021), and CNLC stages (P=0.048). The incidences of postoperative complications before and after PSM were lower in the LH group than in the OH group (P=0.007 and 0.003, respectively). There were no significant differences in the overall survival (OS) and recurrence-free survival (RFS) between the two groups (P=0.79 and 0.8, respectively). According to the multivariable Cox regression analyses, the largest tumor size (P<0.0001) and tumor number (P=0.004) were significant and independent prognostic factors of OS.

Conclusion

In our study, we found that LH is technically feasible and safe in patients after conversion therapy. Compared with OH, LH showed similar OS and RFS and was associated with fewer postoperative complications.

Predictors of recurrence following laparoscopic minor hepatectomy for hepatocellular carcinoma in the UK

AIMS

Minor hepatectomy, which is increasingly carried out laparoscopically (LLR), is a cornerstone of curative treatment for hepatocellular carcinoma (HCC). The majority of relevant publications however originate from regions with endemic viral hepatitis. Although the incidence of HCC in the UK is increasing, little is known about outcomes following LLR.

METHODS

Consecutive patients undergoing minor (involving ≤2 segments) LLR or open resection (OLR) at our institute between 2014 and 2021 were compared. Selection from a plethora of factors potentially impacting on overall (OS) and disease free survival (DFS) was optimised with Lasso regression. To enable analysis of patients having repeat resection, multivariate frailty modelling was utilised to calculate hazard ratios (HR).

RESULTS

The analysis of 111 liver resections included 55 LLR and 56 OLR. LLR was associated with a shorter hospital stay (5 ± 2 vs. 7 ± 2 days; p < 0.001) and a lower comprehensive complication index (4.43 vs. 9.96; p = 0.006). Mean OS (52.3 ± 2.3 vs. 49.9 ± 3.0 months) and DFS (33.9 ± 3.4 vs. 36.5 ± 3.6 months; p = 0.59) were comparable between LLR and OLR, respectively (median not reached). Presence of mixed cholangiocarcinoma/HCC, satellite lesions and AFP level predicted OS and DFS. In addition tumour size was predictive of DFS.

CONCLUSIONS

In the studied population minor LLR was associated with shorter hospital stay and fewer complications while offering non-inferior long-term outcomes. A number of predictors for disease free survival have been elucidated that may aid in identifying patients with a high risk of disease recurrence and need for further treatment.

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.

Current status of laparoscopic hepatectomy for the treatment of hepatocellular carcinoma: A systematic literature review

BACKGROUND

Laparoscopic hepatectomy (LH) was first introduced in the 1990s and has now become widely accepted for the treatment of hepatocellular carcinoma (HCC). Laparoscopic liver resection (LLR) is considered a safe and effective approach for liver disease. However, the role of laparoscopic hepatectomy in HCC with cirrhosis remains controversial and needs to be further assessed, and the present literature review aimed to review the surgical and oncological outcomes of Laparoscopic hepatectomy (LH). According to Hong and colleagues laparoscopic resection for liver cirrhosis is a very safe and feasible procedure for both ideal cases and select patients with high risk factors [29]. The presence of only 1 of these factors does not represent an absolute contraindication for LH.

METHODS AND RESULTS

We selected 23 studies involving about 1363 HCC patients treated with LH. 364 (27%) patients experienced major resections. The mean operative time was 244.9 minutes, the mean blood loss was 308.1 mL and blood transfusions were required in only 4.9% of patients. There were only 2 (0.21%) postoperative deaths and overall morbidity was 9.9%. Tumor recurrence ranged from 6 to 25 months. The 1-year, 3-year, and 5-year disease free Survival (DFS) rates ranged from 71.9% to 99%, 50.3% to 91.2%, and 19% to 82% respectively. Overall survival rates ranged from 88% to 100%, 73.4% to 94.5%, and 52.6% to 94.5% respectively.

CONCLUSIONS

In our summery LH is lower risk and safer than conventional open liver surgery and is just as efficacious. Also, the LH approach decreased blood-loss, operation time, postoperative morbidity and had a lower conversion rate compared to other procedures whether open or robotic. Finally, LH may serve as a promising alternative to open procedures.

Clinical Experience of Mini-Open Hepatectomy to Aid a Laparoscopic Approach: A Case Series

Introduction

Laparoscopic surgery is recently becoming widespread in the area of liver treatment. However, mobilization of the liver is difficult using laparoscopy alone because of its volume and weight. Ensuring a wider visual field and controlling blood loss are also difficult. We used a hybrid approach involving direct vision and laparoscopy for performing hepatectomy through a small incision to overcome these problems.

Case Presentation

Mini-open hepatectomy was performed on 64 patients between January 2010 and December 2013. Mobilization of the liver was performed using the smallest possible laparotomy incision. Detachment of right or left triangular ligaments was done using laparoscopy because direct vision of the operation field was impossible. Hepatectomy was performed through a small laparotomy incision. Most operations (47%) involved partial resections. Of these, segmentectomies were performed on 20 patients, whereas lobectomy was performed on 7 patients. The median intraoperative bleeding was 565 mL, and the operative time was 247 minutes. The median postoperative hospital stay was 14 days. There was no postoperative mortality.

Conclusion

We present the clinical use of mini-open hepatectomy to aid the laparoscopic approach with satisfactory short-term results.

Laparoscopic hepatectomy versus open hepatectomy for hepatocellular carcinoma: A propensity case-matched analysis of the long-term survival

Backgrounds/Aims

Despite the widespread popularity of laparoscopic surgery, laparoscopic liver resection (LLR) remains in evolution. This study aimed to compare the long-term outcomes for patients undergoing laparoscopic versus open hepatectomy for hepatocellular carcinoma (HCC) ≤7 cm.

Methods

Patients diagnosed with HCC treated by hepatectomy from October 2000 to May 2019 were included. Excluding tumors larger than 7 cm, 1:2 propensity score matching was performed between laparoscopic and open hepatectomies. The perioperative outcomes, 5-year overall survival (OS) and disease-free survival (DFS) of the two groups were compared.

Results

Forty-five patients who underwent LLR were matched to 90 open hepatectomy (OH) during the same period. LLR group had shorter median hospital stay (5 days vs. 9 days, p=0.00) but required longer operative time (326.0 minutes vs. 272.5 minutes, p=0.018) than the OH group. The 5-year overall survival was better in the LLR group (84.9% vs. 61.1%; p=0.036), though there was no significant difference in the 5-year disease free survival (20.0% vs. 22.2%, p=0.613). The rate of R0 resection was comparable between the 2 groups with a slightly better margin distance in the LLR (5 mm vs. 3 mm, p=0.043).

Conclusions

Laparoscopic liver resection is safe and feasible for cirrhotic patients with HCC size up to 7 cm. It has better short-term outcomes and comparable perioperative blood loss and complication rates. The resection margin is not jeopardized and the 5-year overall and disease-free survivals are comparable with the open group.

New frontiers in liver resection for hepatocellular carcinoma

Liver resection is one of the main curative options for early hepatocellular carcinoma (HCC) in patients with cirrhosis and is the treatment of choice in non-cirrhotic patients. However, careful patient selection is required to balance the risk of postoperative liver failure and the potential benefit on long-term outcomes. In the last decades, improved surgical techniques and perioperative management, as well as better patient selection, have enabled the indications for liver resection to be expanded. In this review, we aim to describe the main indications for liver resection in the management of HCC, its role compared to percutaneous ablation and liver transplantation in the therapeutic algorithm, as well as the recent advances in liver surgery that could be used to improve the prognosis of patients with HCC.

Laparoscopic Liver Surgery: What Are the Advantages in Patients with Cirrhosis and Portal Hypertension? Systematic Review and Meta-Analysis with Personal Experience

Background: Laparoscopic surgery is a choice of treatment for liver diseases; it can decrease postoperative morbidity and length of hospital stay (LOS). Hepatocellular carcinoma (HCC) in patients with cirrhosis and portal hypertension may benefit from minimally invasive liver resections (MILRs) instead of open liver resections (OLRs). Whether minimally invasive approaches are superior to conventional ones is still a matter of debate. We thus aimed to gather the available literature on this specific topic to achieve greater clarity. Materials and Methods: PubMed, EMBASE and Web of Sciences databases were assessed for studies comparing OLRs versus MILRs for HCC in cirrhotic patients up to February 2020. Data from our surgical experience from June 2010 to February 2020 were also included. Demographic characteristics, liver function, the presence of portal hypertension, tumor number, and tumor size and location were assessed; operative time, need for Pringle maneuver, estimated blood loss (EBL), major or minor hepatectomy performance, and conversion rate were evaluated for operative findings. Postoperative outcomes and liver-related complications, surgical site infection (SSI) rate, blood transfusion (BT) rate, need for reintervention, LOS, in-hospital or 30-day mortality, and radicality of resection were also considered. Meta-analysis was performed employing Review Manager 5.3 software. Results: One thousand three hundred twenty-one patients from 13 studies and our own series were considered in the meta-analysis. At preoperative settings, the OLR and MILR groups differed significantly only by tumor size (4.4 versus 3.0, P = .006). Laparoscopic procedures resulted significantly faster (120.32-330 minutes versus 146.8-342.75 minutes, P = .002) and with lower EBL than open ones (88-483 mL versus 200-580 mL, P < .00001), thus requiring less BTs (7.9% versus 13.2%, P = .02). In terms of overall morbidity, minimally invasive surgeries resulted significantly favorable (19.32% versus 38.04%, P < .00001), as well as for ascites (2.7% versus 12.9% P < .00001), postoperative liver failure (7.51% versus 13.61% P = .009), and SSI (1.8% versus 5.42%, P = .002). Accordingly, patients who had undergone MILRs had significantly shorter postoperative hospitalization than patients who underwent conventional open surgery (2.4-36 days versus 4.2-19 days P < .00001). Both groups did not differ in terms of mortality rate and radicality of resection (OLR 93.8% versus 96.1% laparoscopic liver resection, P = .12). Conclusions: Based on the available evidence in the literature, laparoscopic resections rather than open liver ones for HCC surgery in cirrhotic patients seem to reduce postoperative overall morbidity, liver-specific complications, and LOS. The lack of randomized studies on this topic precludes the possibility of achieving defining statements.

Short-term Results of Laparoscopic versus Open Liver Resection for Liver Metastasis from Colorectal Cancer: A Comparative Study

Laparoscopic liver resection is currently performed in an increasing number of institutions as a minimally invasive treatment. However, no randomized controlled trials have compared laparoscopic and open liver resections. Twenty-three laparoscopic and 24 open liver resections for colorectal cancer liver metastases (CRCLM) were performed, and these data for both were retrospectively compared in the short-term results. The estimated blood loss was 99 ± 207 mL in the laparoscopic group and 397 ± 381 mL in the open group ( P = 0.0018); blood loss was significantly higher in the open group. There were no differences in the surgical procedure, blood loss, transfusion rate, pathological margins, postoperative complications, 30-day mortality, duration of intravenous drip, or hospital stay. On postoperative courses, the values of total bilirubin, white blood cell count, and C-reactive protein were significantly lower in the laparoscopic group. The data of the present series suggest the lesser invasiveness and safety of laparoscopic liver resection even for patients with CRCLM, and they showed that postoperative laboratory tests were better after laparoscopy than after the traditional open approach with better short-term results. Tumor diameter less than 5 cm appears to be the appropriate indication for laparoscopic liver resection for CRCLM.

Clinical outcome of open surgery versus laparoscopic surgery for cirrhotic hepatocellular carcinoma patients: a meta-analysis

BACKGROUND AND AIM

Open surgery remains the major approach to treat hepatocellular carcinoma, and laparoscopy-assisted liver resection has been recommended as a superior treatment. However, the efficacy of laparoscopic surgery versus open surgery for cirrhotic patients is under debate. Therefore, the aim of this meta-analysis was to compare the clinical outcomes of laparoscopic and open resection of hepatocellular carcinoma in patients with cirrhosis.

METHODS

Electronic databases were searched for eligible literature updated on November 2018. After rigorous review of quality, the data were extracted from eligible trials. All the data were pooled with the corresponding 95% confidence interval using RevMan software. Sensitivity analyses and heterogeneity were quantitatively evaluated.

RESULTS

Fourteen trials met the inclusion criteria. According to the pooled result of surgery duration, laparoscopic surgery was associated with significantly shorter hospital stay [STD mean difference (SMD) = -0.61, 95% confidence interval -0.89 to -0.32; P < 0.0001], lower intraoperative blood loss (SMD = -0.56, 95% confidence interval -0.99 to -0.12; P = 0.01), fewer complications (odds ratio = 0.38, 95% confidence interval 0.28 to 0.52; P < 0.00001) and lower transfusion rate (odds ratio = 0.58, 95% confidence interval 0.36-0.93; P = 0.02). Nevertheless, there was no remarkable difference in operative time (SMD = 0.17, 95% confidence interval -0.25 to -0.59; P = 0.42) between the two groups. The pooled analysis of overall survival showed that laparoscopic surgery did not achieve benefit compared with open surgery (P = 0.02). Moreover, the pooled results of three subgroups indicated that laparoscopic surgery was associated with significantly better disease-free survival (P < 0.05).

CONCLUSION

The current analysis indicates that laparoscopic liver resection for hepatocellular carcinoma improved intraoperative and disease-free survival, with similar overall survival compared to the open procedure. Laparoscopic surgery may serve as a safe and feasible alternative for selected hepatocellular carcinoma patients with cirrhosis.

Robotic approach to the liver: Open surgery in a closed abdomen or laparoscopic surgery with technical constraints?

The application of the minimally invasive approach has shown to be safe and effective for liver surgery and is in constant growth. The indications for laparoscopic surgery are steadily increasing across the field. In the early 2000s, robotic surgery led to some additional improvements, such as tremor filtration, instrument stability, 3D view and more comfort for the surgeon. These techniques bring in some advantages compared to the traditional OLR: less blood loss, shorter admissions, fewer adhesions, and a faster postoperative recovery and better outcomes in case of further hepatectomy for tumor recurrence has been shown. Concerning which is the best minimally invasive approach between laparoscopic and robotic surgery, the evidence is still conflicting. The latter shows good potential, since the endo-wristed instruments work similarly to the surgeon's hands, even with an intact abdominal wall. However, the technique is still under development, burdened by important costs, and limited by the lack of some instruments available for the laparoscopic approach. The paucity of universally accepted and proven data, especially concerning long-term outcomes, hampers drawing univocal acceptance at present. Furthermore, the number of variables related both to the patient and the disease further complicates the decision leading to a treatment tailored to each patient with strict selection. This review aims to explore the main differences between laparoscopic and robotic surgery, focusing on indications, operative technique and current debated clinical issues in recent literature.

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.

Preoperative Prognosticators of Safe Laparoscopic Hepatocellular Carcinoma Resection in Advanced Cirrhosis: a Propensity Score Matching Population-Based Analysis of 1799 Western Patients

BACKGROUND

The safety and oncologic outcomes of patients with advanced cirrhosis undergoing laparoscopic liver resection (LLR) compared to open resection (OLR) for hepatocellular carcinoma (HCC) remain unclear.

METHODS

Patients with HCC resection during 2010-2014 were identified from the National Cancer Database. Patients with severe fibrosis; single lesions; M0; and known grade, margin status, tumor size, length of hospital stay, 30- and 90-day mortality, 30-day readmission, surgical approach, and complete follow-up were included. A 1:1 propensity score matching analysis of LLR:OLR was performed. Prognostic effect of LLR was assessed by multivariable Cox proportional hazards model.

RESULTS

A total of 1799 hepatectomy patients (minor (n = 491, 27.3%); major (n = 1308, 72.7%)) were included. Of 193 (10.7%) LLR patients, 190 were eligible for matching. The LLR vs OLR did not differ for patient characteristics, resection margin status, and 30-day (p = 0.141), 90-day mortality (p = 0.121), or 30-day readmission (p = 0.784). Median hospital stay was shorter for LLR (6 vs 8 days, p = 0.001). Median overall survival (OS) was similar for LLR vs OLR (44.2 and 39.5 months, respectively, p = 0.064). Predictors of worse OS were older age (hazard ratio (HR) 1.04, p = 0.034), > 2 comorbidities (HR 1.29, p = 0.012), grade 3-4 disease (HR 1.81, p = 0.025), N1 disease (HR 1.04, p = 0.048), and R1 margins (HR 1.34, p = 0.002). After adjustment for confounders, LLR vs OLR was not a significant risk factor for OS (HR 1.14, 95% CI 0.76-1.71, p = 0.522).

CONCLUSION

While LLR in advanced cirrhosis for patients with HCC proved safe, optimal patient selection based on the preoperatively available factors comorbidities, age, degree of underlying liver disease, and high-quality oncologic surgery will determine long-term survival.

Current topics in liver surgery

Liver resection is one of the main treatment strategies for liver malignancies. Mortality and morbidity of liver surgery has improved significantly with progress in selection criteria, development of operative procedures and improvements in perioperative management. Safe liver resection has thus become more available worldwide. We have identified four current topics related to liver resection (anatomical liver resection, laparoscopic liver resection, staged liver resection and chemotherapy-induced liver injury). The balance between treatment effect and patient safety needs to be considered when planning liver resection. Progress in this area has been rapid thanks to the efforts of many surgeons, and outcomes have improved significantly as a result. These topics remain to be solved and more robust evidence is needed. Precise selection of the optimal procedure and risk evaluation should be standardized with further development of each topic. The present article reviews these four current topics with a focus on safety and efficacy in recent series.

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

AIM

The aim of this study was to evaluate the surgical safety and effectiveness of laparoscopic hepatectomy (LH) in short- and long-term outcomes compared to open hepatectomy (OH) in patients treated for hepatocellular carcinoma (HCC).

METHODS

An electronic search of reports published before August 2017 was carried out to identify comparative studies evaluating LH versus OH for HCC.

RESULTS

A total of 5889 patients (2421 underwent LH; 3468 underwent OH) were included in our meta-analysis from 47 studies. Laparoscopic hepatectomies were associated with favorable outcomes in terms of operative blood loss (mean difference [MD], -147.27; 95% confidence interval [CI], -217.00, -77.55), blood transfusion requirement (odds ratio [OR], 0.51; 95% CI, 0.40, 0.65), pathologic resection margins (MD, 0.07; 95% CI, 0.02, 0.12; P = 0.01), R0 resection rate (OR, 1.34; 95% CI, 0.98, 1.84; P = 0.07), and length of hospital stay (MD, -5.13; 95% confidence interval, -6.23, -4.03). There were no differences between the groups in overall survival (OS) at 1 year (OR, 1.41; 95% CI, 1.00, 1.98), 3 years (OR, 1.12; 95% CI, 0.93, 1.36), or 5 years (OR, 1.18; 95% CI, 0.94, 1.46), in disease-free survival (DFS) at 1 (OR, 1.19; 95% CI, 0.94, 1.51), 3 years (OR, 1.07; 95% CI, 0.86, 1.33), or 5 years (OR, 1.13; 95% CI, 0.92, 1.40), or in recurrence (OR, 0.90; 95% CI, 0.74, 1.08).

CONCLUSION

Compared to OH, LH is superior in terms of lower intraoperative blood loss and the requirement for blood transfusion, larger pathologic resection margins, increased R0 resection rates, and shorter length of hospital stay. Laparoscopic hepatectomy and OH have similar OS, DFS, and recurrence.

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.

The Asia Pacific Consensus Statement on Laparoscopic Liver Resection for Hepatocellular Carcinoma: A Report from the 7th Asia-Pacific Primary Liver Cancer Expert Meeting Held in Hong Kong

BACKGROUND

Laparoscopic liver resection has been gaining momentum, and it has become an accepted practice after the two international consensus conferences where experts worked up guidelines to standardize this approach and improve its safety. However, most laparoscopic hepatectomies were performed in patients with liver metastases. The concurrent presence of liver cirrhosis with hepatocellular carcinoma (HCC) poses a great challenge to clinicians trying to establish a routine use of laparoscopic liver resection for HCC.

SUMMARY

The first Asia Pacific consensus meeting on laparoscopic liver resection for HCC was held in July 2016 in Hong Kong. A group of expert liver surgeons with experience in both open and laparoscopic hepatectomy for HCC convened to formulate recommendations on the role and perspective of laparoscopic liver resection for primary liver cancer. The recommendations consolidate the most recent evidence pertaining to laparoscopic hepatectomy together with the latest thinking of practicing clinicians involved in laparoscopic hepatectomy, and give detailed guidance on how to deploy the treatment effectively for patients in need.

KEY MESSAGE

The panel of experts gathered evidence and produced recommendations providing guidance on the safe practice of laparoscopic hepatectomy for patients with HCC and cirrhosis. The inherent advantage of the laparoscopic approach may result in less blood loss if the procedure is performed in experienced centers. The laparoscopic approach to minor hepatectomy, particularly left lateral sectionectomy, is a preferred practice for HCC at experienced centers. Laparoscopic major liver resection for HCC remains a technically challenging operation, and it should be carried out in centers of excellence. There is emerging evidence that laparoscopic liver resection produces a better oncological outcome for HCC when compared with radiofrequency ablation, particularly when the lesions are peripherally located. Augmented features in laparoscopic liver resection, including indocyanine green fluorescence, 3D laparoscopy, and robot, will become important tools of surgical treatment in the near future. A combination of all of these features will enhance the experience of the surgeons, which may translate into better surgical outcomes. This is the first consensus workforce on laparoscopic liver resection for HCC, which is a unique condition that occurs in the Asia Pacific region.

Short- and Long-Term Results of Laparoscopic Parenchyma-Sparing Hepatectomy for Small-Sized Hepatocellular Carcinoma: A Comparative Study Using Propensity Score Matching Analysis

The aim of this study was to evaluate the degree of invasiveness and the clinical outcomes of laparoscopic parenchyma-sparing hepatectomy (LPSH) for a maximum hepatocellular carcinoma (HCC) size ≤5 cm. Sixty-one LPSHs and 175 open parenchyma-sparing hepatectomies (OPSHs) for small-sized HCC were analyzed using a propensity score matching analysis. The median operative time was significantly shorter in the LPSH group (194 min) than in the OPSH group (275 minutes) ( P < 0.0001). The estimated blood loss was significantly lower in the LPSH group (100 mL) than in the OPSH group (380 mL) ( P < 0.0001). The incidences of superficial incisional surgical site infections and respiratory complications were significantly lower in the LPSH group than in the OPSH group ( P = 0.0161 and 0.0285, respectively). During the postoperative course, the white blood cell counts and C-reactive protein levels were significantly lower in the LPSH group. There were no differences in overall survival and disease-free survival ( P = 0.1293 and 0.4039, respectively), and no significant differences in terms of type of recurrence and site of intrahepatic recurrence ( P = 0.1410). The data from the present series suggest the lesser invasiveness and safety of LPSH even for small-sized HCC patients.

Laparoscopic Versus Open Hepatic Resection for Solitary Hepatocellular Carcinoma Less Than 5 cm in Cirrhotic Patients: A Randomized Controlled Study

BACKGROUND

Current literature is lacking level 1 evidence for surgical and oncologic outcomes of hepatocellular carcinoma (HCC) undergoing laparoscopic versus open hepatectomy. Aim was to compare feasibility, safety, and surgical and oncologic efficiency of laparoscopic versus open liver resection (OLR) in management of solitary small (<5 cm) peripheral HCC in Child A cirrhotic patients.

METHODS

Patients were randomly assigned to either OLR group (25 patients) or laparoscopic liver resection (LRR) group (LRR: 25 patients). All were treated with curative intent aiming at achieving R0 resection using radiofrequency-assisted technique.

RESULTS

LLR had significantly less operative time (120.32 ± 21.58 versus 146.80 ± 16.59 minutes, P < .001) and shorter duration of hospital stay (2.40 ± 0.58 versus 4.28 ± 0.79 days, P < .001), with comparable overall complications (25 versus 28%, P = .02). LLR had comparative resection time (66.56 ± 23.80 versus 59.56 ± 14.74 minutes, P = .218), amount of blood loss (250 versus 230 mL, P = .915), transfusion rate (P = 1.00), and R0 resection rate when compared with OLR. After median follow-up of 34.43 (31.67-38.60) months, LLR achieved similar adequate oncological outcome of OLR, no local recurrence, with no significant difference in early recurrence or number of de novo lesions (P = .49). One-year and 3-year disease free survival (DFS) rates, 88% and 59%, in the LLR were comparable to corresponding rates of 84% and 54% in OLR (P = .9).

CONCLUSION

LLR is superior to the OLR with significantly shorter duration of hospital stay and does not compromise the oncological outcomes.

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.

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.

Outcomes of Laparoscopic Liver Resection for Patients with Large Colorectal Liver Metastases: A Case-Matched Analysis

BACKGROUND

Despite the expansion of laparoscopic approach in the treatment of liver tumors, limited data have been reported regarding large colorectal liver metastases (CRLMs). This study aimed at assessing the short- and long-term outcomes after laparoscopic liver resection (LLR) for large (≥5 cm) CRLMs.

METHODS

This was a case-matched study (1:2) comparing patients with large (group L; ≥5 cm) and small (group S; <5 cm) CRLMs using demographic, tumor, and surgical characteristics as matching variables. Postoperative outcomes and survival data were compared in the 2 groups.

RESULTS

Forty patients who underwent LLR for large CRLMs were matched with 80 patients with tumors <5 cm. Major hepatectomy was performed with 75.0 % of patients in Group L and 66.3 % in group S (p = 0.403). Operative time was 300 min in group L and 240 min in group S (p = 0.059). The postoperative mortality and overall morbidity rates were comparable in the 2 groups (p = 1.000 and 0.170, respectively). Postoperative major complication (Dindo-Clavien ≥3) was similar between the two groups (p = 0.072). R0 resection was achieved in 92.5 % in the group L and in 95.0 % in the group S (p = 1.000). The 5-year overall survival and recurrence-free survival were better for group S than for group L (47.3 vs. 35.4 %, p = 0.044 and 27.3 vs. 14.9 %, p = 0.042, respectively). Multivariate analysis identified positive surgical margins and synchronous presentation as prognostic factors.

CONCLUSION

Since LLR was performed safely with favorable oncological adequacy in selected patients with large CRLMs, tumor size should not modify the surgical approach.

Is Laparoscopic Hepatectomy a Safe, Feasible Procedure in Patients with a Previous Upper Abdominal Surgery?

Background:

Laparoscopic liver resection has become an accepted treatment for liver tumors or intrahepatic bile duct stones, but its application in patients with previous upper abdominal surgery is controversial. The aim of this study was to evaluate the feasibility and safety of laparoscopic hepatectomy in these patients.

Methods:

Three hundred and thirty-six patients who underwent laparoscopic hepatectomy at our hospital from March 2012 to June 2015 were enrolled in the retrospective study. They were divided into two groups: Those with previous upper abdominal surgery (PS group, n = 42) and a control group with no previous upper abdominal surgery (NS group, n = 294). Short-term outcomes including operating time, blood loss, hospital stay, morbidity, and mortality were compared among the groups.

Results:

There was no significant difference in median operative duration between the PS group and the NS group (180 min vs. 160 min, P = 0.869). Median intraoperative blood loss was same between the PS group and the control group (200 ml vs. 200 ml, P = 0.907). The overall complication rate was significantly lower in the NS group than in the PS group (17.0% vs. 31.0%, P = 0.030). Mortality and other short-term outcomes did not differ significantly between groups.

Conclusions:

Our study showed no significant difference between the PS group and NS group in term of short-term outcomes. Laparoscopic hepatectomy is a feasible and safe procedure for patients with previous upper abdominal surgery.

Laparoscopic Liver Resection of Hepatocellular Carcinoma with a Tumor Size Larger Than 5 cm: Review of 45 Cases in a Tertiary Institution

INTRODUCTION

Although laparoscopic liver resection (LLR) has developed rapidly, its usefulness for the treatment of large tumors is less clear, due to concerns about compromising oncological principles and patient safety. The purpose of this study was to explore the feasibility and safety of LLR for the treatment of hepatocellular carcinoma (HCC) with a tumor size larger than 5 cm.

PATIENTS AND METHODS

From January 2007 to December 2014, we performed LLR in 45 patients with HCC with a tumor size ≥5 cm. Perioperative outcome, tumor recurrence, and overall patient survival were analyzed.

RESULTS

Median age was 60 years (interquartile range [IQR] 52-68) and 64.4% (29/45) were male. Seven patients (15.6%) had larger than 10 cm of HCC. No operative deaths occurred and six of the laparoscopic procedures were converted to open resection (conversion rate 13.3%). Median operation time was 365 minutes (IQR 277-443) and median estimated blood loss (EBL) was 400.0 mL (IQR 275-600). There was no R1 or R2 resection and median resection margin was 19.0 mm (IQR 8.0-33.0). Complications above Clavien-Dindo classification grade III occurred in four patients (8.9%). The median overall follow-up time was 10.7 month (range 1.1-62.1). One-year recurrence free survival (RFS) and overall survival (OS) were 86.0% and 95.5%, and 3-year RFS and OS were 70.7% and 86.0%.

CONCLUSION

LLR appears safe and feasible in patients with HCC with a tumor size larger than 5 cm. Expansion of indication for LLR in patients with HCC may be considered.

Surgical resection of localized hepatocellular carcinoma: patient selection and special consideration

Localized hepatocellular carcinoma (HCC) refers to a solitary or few tumors located within either the left or right hemiliver without evidence of bilobar or extrahepatic spread. This term encompasses a heterogeneous morphology with no regard to stage of prognosis of the disease. Surgical resection remains the mainstay of curative treatment for the localized HCC. Various biochemical and radiological tests constitute an indispensible part of preoperative assessment. Emergence of laparoscopic hepatectomy has brought liver resection into a new era. Improved understanding of the pathophysiology of HCC allows more aggressive surgical resection without compromising outcomes. New insights into the management of special situations, such as ruptured HCC, pyogenic transformation of HCC, and HCC with portal vein tumor thrombus, rekindle the hopes of curative resection in these terminal events. Amalgamating salvage liver transplantation into the surgical management of resectable HCC has revolutionized the treatment paradigm of this deadly disease.

Prospective cohort study of laparoscopic and open hepatectomy for hepatocellular carcinoma

BACKGROUND

The safety and feasibility of laparoscopic hepatectomy for hepatocellular carcinoma (HCC) with a diameter of 5 cm or less is well recognized. The role of laparoscopy in treating large HCC (5-10 cm) remains controversial. This prospective cohort study was undertaken to assess the short- and long-term outcomes of laparoscopic hepatectomy for large HCC and to compare this approach with open hepatectomy.

METHODS

Patients with a solitary HCC (diameter 5-10 cm) who underwent open or laparoscopic hepatectomy were enrolled in a prospective observational study from January 2012 to April 2015. Perioperative and follow-up data were analysed.

RESULTS

Some 128 patients underwent laparoscopic hepatectomy and 207 had an open hepatectomy. One and two perioperative deaths were reported in the laparoscopic and open groups respectively. Laparoscopic hepatectomy was converted to an open procedure in 12 (9·4 per cent) of 128 patients. More patients in the laparoscopic group underwent an anatomical hepatectomy than in the open group (45·3 versus 21·7 per cent; P = 0·001). The postoperative complication rate was 20·3 per cent for the laparoscopic group versus 35·7 per cent for the open group (P = 0·003). Mean(s.d.) duration of hospital stay was 11·4(3·1) and 15·8(7·7) days respectively (P < 0·001). One- and 3-year overall survival rates in the laparoscopic and open groups were 94·4 versus 93·6 per cent (P = 0·875), and 81·4 versus 82·2 per cent (P = 0·802), respectively. One- and 3-year disease-free survival rates were 89·4 versus 88·7 per cent (P = 0·825), and 67·3 versus 66·7 per cent (P = 0·902), respectively.

CONCLUSION

Laparoscopic hepatectomy is safe and feasible for the treatment of patients with large HCC.

Review of 103 Cases of Laparoscopic Repeat Liver Resection for Recurrent Hepatocellular Carcinoma

INTRODUCTION

Laparoscopic repeat liver resection (LRLR) has been shown in small retrospective studies to be a safe and effective treatment for recurrent hepatocellular carcinoma (rHCC) in selected patients. The aim of this study was to perform a systematic review of the current literature to determine the safety, feasibility, and oncologic integrity of LRLR for rHCC.

METHODS

A computerized search of the PubMed database was performed for all English language studies evaluating LRLR for HCC from January 1, 2005 to March 31, 2016.

RESULTS

Ten studies reporting on 103 patients were included in this review. 30/51 (58.5%) patients had liver cirrhosis. In 66/95 (69.5%) patients, the index surgery was an open resection and this was a major hepatectomy in 8/49 (16.3%) patients. In 17/72 (23.6%) patients, LRLR was performed for tumors in the posterosuperior segments and in 21/60 (35%) for ipsilateral HCC recurrence. The median tumor size of rHCC ranged from 17-40 mm and 8/69 (11.6%) LRLR were for multifocal rHCC. In 100/103 (97%) patients LRLR was attempted via pure laparoscopy and 2 (1.9%) required open conversion. Median operation time of LRLR ranged from 73-343 minutes and the median blood loss ranged from 50 to 297 mL. The reported postoperative morbidity was 24/97 (24.7%) and there was no postoperative mortality. The median postoperative length of stay ranged from 3.5 to 11 days. Three studies compared the outcomes of LRLR versus open resection for rHCC and all three demonstrated a significant decrease in blood loss in favor of LRLR.

CONCLUSION

In highly selected patients; LRLR for rHCC is feasible and safe. LRLR can be performed for patients with previous open LR, previous major hepatectomy, two previous LR, multiple tumors, liver cirrhosis, ipsilateral HCC recurrence, and cancers located in the difficult posterosuperior segments. Comparative studies have demonstrated that LRLR is superior to open repeat liver resection in terms of perioperative outcomes such as decreased blood loss and length of stay.

Perioperative and oncologic outcomes of minimally invasive liver resection for colorectal metastases: A case-control study of 130 patients

BACKGROUND

Our aim was to compare the perioperative and oncologic outcomes of open liver resection and minimally invasive liver resection in the management of colorectal liver metastases.

METHODS

Patients who underwent minimally invasive liver resection for colorectal liver metastases between January 2006 and June 2015 at a single center were identified and matched by extent of resection to consecutive open liver resection patients from the same period. Clinicopathologic characteristics, perioperative data, recurrence, and survival outcomes were collected and analyzed based on intention-to-treat.

RESULTS

Sixty-five patients underwent minimally invasive liver resection during this period and were matched to 65 consecutive open liver resection patients, with similar baseline demographic, tumor, and chemotherapy parameters. Conversion to open occurred in 5 (7.7%) minimally invasive liver resection patients. R0 resection rates and operative times were comparable, but the estimated blood loss was less in the minimally invasive liver resection group (median 200 mL vs 400 mL, P < .001), as were perioperative transfusion rates (4.6% vs 15.4%, P = .04). The duration of stay was shorter after minimally invasive liver resection (median 4 days vs 6 days, P < .001), while major and minor complication rates were similar and no perioperative mortality was recorded. At a median follow-up of 28 months, there was no difference regarding disease-free (P = .90) or overall survival (P = .37).

CONCLUSION

In selected patients with colorectal liver metastases, minimally invasive liver resection resulted in similar oncologic outcomes, with decreased blood loss and shorter duration of stay compared to patients who underwent open liver resection.

A comparison of perioperative outcomes in elderly patients with malignant liver tumors undergoing laparoscopic liver resection versus radiofrequency ablation

BACKGROUND

Liver resection is the treatment option with the best chance for cure in patients with malignant liver tumors. However, there are concerns regarding postoperative recovery in elderly patients, which may lead to a preference of non-resectional therapies over hepatectomy in this patient population. Although laparoscopic liver resection (LLR) is associated with a faster recovery compared to open hepatectomy, there are scant data on how elderly patients tolerate LLR. The aim of this study was to analyze the perioperative outcomes of LLR in elderly patients with hepatic malignancies, with a comparison to laparoscopic RFA (LRFA).

METHODS

A retrospective analysis of a prospective database for liver tumors identified a total of 82 patients older than 65 years who underwent laparoscopic treatment of their liver tumors in a single tertiary care center between 2000 and 2014. These patients were equally distributed into LLR and LRFA treatment arms.

RESULTS

Mean age, American Society of Anesthesiologists (ASA) score and tumor type (predominantly metastatic colorectal cancer) were similar in both groups. Patients in the LRFA group had more tumors (2.1 ± 1.8 vs. 1.2 ± 0.6, p < 0.01), whereas tumors were larger in the LLR group (3.8 ± 1.6 vs. 2.8 ± 1.1 cm, p < 0.01). Although the operative time (116 vs. 214 min, p < 0.01) and hospital stay (2.1 vs. 3.4 days, p = 0.010) were shorter for the LRFA versus LLR group, respectively, morbidity (4.8 vs. 7.3 %) and mortality (0 vs. 0 %) were similar. Local recurrence was significantly higher in the LRFA versus LLR group (29 vs. 2.4 %, respectively, p = 0.002). However, there was no statistical difference in disease-free and overall survival between two groups (28 vs. 30 and 51 vs. 54 months, p = 0.443 and 0.768, respectively).

CONCLUSIONS

This study showed that LLR was tolerated as well as LRFA in elderly patients with similar comorbidities. We suggest LLR to be considered as an option in selected elderly patients who are deemed poor candidates for open hepatectomy.

Comparative Short-term Benefits of Laparoscopic Liver Resection: 9000 Cases and Climbing

OBJECTIVE

To perform a systematic review of worldwide literature on laparoscopic liver resections (LLR) and compare short-term outcomes against open liver resections (OLR) by meta-analyses.

SUMMARY BACKGROUND DATA

There are no updated pooled data since 2009 about the current status and short-term outcomes of LLR worldwide.

PATIENTS AND METHODS

All English language publications on LLR were screened. Descriptive worldwide data and short-term outcomes were obtained. Separate analyses were performed for minor-only and major-only resection series, and series in which minor/major resections were not differentiated. Apparent case duplications were excluded.

RESULTS

A set of 463 published manuscripts were reviewed. One hundred seventy-nine single-center series were identified that accounted for 9527 LLR cases worldwide. Minor-only, major-only, and combined major-minor series were 61, 18, and 100, respectively, including 32, 8, and 43 comparative series, respectively. Of the total 9527 LLR cases reported, 6190 (65%) were for malignancy and 3337 (35%) were for benign indications. There were 37 deaths reported (mortality rate = 0.4%). From the meta-analysis comparing case-matched LLR to OLR (N = 2900 cases), there was no increased mortality and significantly less complications, transfusions, blood loss, and hospital stay observed in LLR vs OLR.

CONCLUSIONS

This is the largest review of LLR available to date with over 9000 cases published. It confirms growing safety when performed in selected patients and by trained surgeons, and suggests that LLR may offer improved patient short-term outcomes compared with OLR. Improved levels of evidence, standardized reporting of outcomes, and assuring proper training are the next challenges of laparoscopic liver surgery.

Laparoscopic repeat liver resection for recurrent hepatocellular carcinoma

BACKGROUND

Repeat liver resection is effective for recurrent hepatocellular carcinoma (rHCC). This study aimed to determine the outcomes of laparoscopic repeat liver resection (LRLR) for rHCC.

METHODS

Eight consecutive patients who underwent LRLR for rHCC were retrospectively reviewed.

RESULTS

Six patients had previous open and two had laparoscopic liver resection (LLR). There was one (12.5%) open conversion for bleeding and one (12.5%) post-operative morbidity. The median tumour size was 24 mm (range: 8-50 mm). LRLR was performed for rHCC in the ipsilateral lobe as compared to the index surgery in 4/8 (50%) patients. Five of eight (62.5%) patients had rHCC in the difficult posterosuperior segments. Six patients had previous open LR, and two had previous LLR. One patient (patient 4) had two prior open LR for rHCC, and LRLR was performed for the second recurrence. The median duration from the first surgery to LRLR was 29 months (range: 6-109 months). The median post-operative stay was 3.5 days. All eight patients had R0 resections, and at a median follow-up of 7.5 months, all patients were disease-free.

CONCLUSION

LRLR for rHCC is feasible and safe. This can be performed even for patients with previous open liver resections, cirrhosis, lesions in the posterosuperior segments and prior LR of the ipsilateral lobe. LRLR for rHCC is feasible and safe in highly selected patients.

The safety and efficacy of approaches to liver resection: a meta-analysis

Background:

The aim of this study is to compare the safety and efficacy of conventional laparotomy with those of robotic and laparoscopic approaches to hepatectomy.

Database:

Independent reviewers conducted a systematic review of publications in PubMed and Embase, with searches limited to comparative articles of laparoscopic hepatectomy with either conventional or robotic liver approaches. Outcomes included total operative time, estimated blood loss, length of hospitalization, resection margins, postoperative complications, perioperative mortality rates, and cost measures. Outcome comparisons were calculated using random-effects models to pool estimates of mean net differences or of the relative risk between group outcomes. Forty-nine articles, representing 3702 patients, comprise this analysis: 1901 (51.35%) underwent a laparoscopic approach, 1741 (47.03%) underwent an open approach, and 60 (1.62%) underwent a robotic approach. There was no difference in total operative times, surgical margins, or perioperative mortality rates among groups. Across all outcome measures, laparoscopic and robotic approaches showed no difference. As compared with the minimally invasive groups, patients undergoing laparotomy had a greater estimated blood loss (pooled mean net change, 152.0 mL; 95% confidence interval, 103.3–200.8 mL), a longer length of hospital stay (pooled mean difference, 2.22 days; 95% confidence interval, 1.78–2.66 days), and a higher total complication rate (odds ratio, 0.5; 95% confidence interval, 0.42–0.57).

Conclusion:

Minimally invasive approaches to liver resection are as safe as conventional laparotomy, affording less estimated blood loss, shorter lengths of hospitalization, lower perioperative complication rates, and equitable oncologic integrity and postoperative mortality rates. There was no proven advantage of robotic approaches compared with laparoscopic approaches.

Liver resection for hepatocellular carcinoma in patients with portal hypertension: the role of laparoscopy

Liver resection (LR) for hepatocellular carcinoma (HCC) in patients with chronic liver disease (CLD) is a major issue since patients are at risk of serious intraoperative and postoperative complications. The current EASL/AASLD guidelines recommend LR only in case of patients with stage A HCC with well-preserved liver function and consider the presence of portal hypertension (PHT) as a contraindication to surgery. Nevertheless, the literature on this topic is conflicting. Recently several studies reported that favorable outcomes can be achieved with a careful patients' selection in high volume centers. Laparoscopic LR, when performed by well-trained surgeons and with appropriate indications, proved to be a valid option for the surgical treatment of HCC on cirrhosis offering similar oncologic outcomes but a reduction in surgical related morbidities. Laparoscopic LR thanks to a reduction in the incidence of post-operative liver failure and ascites development in comparison to standard open LR could, in selected cases challenge alternative treatments in the treatment of HCC patients with preserved liver function and clinical signs of mild PHT.

The importance of surgical margins in primary malignancies of the liver

Resection is an important treatment modality for hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). Anatomic resection is generally preferred for HCC. When anatomic resection is not feasible, prospective data have demonstrated an improved outcome among HCC patients who have a resection with wide versus narrow surgical margins. Similarly, among patients with ICC, R1 resection has been associated with worse outcomes. In addition, margin width may also impact risk of recurrence and survival. As such, provided adequate functional liver remnant remains, anatomic resection with wide margins is recommended for HCC and ICC.

Comparative study and systematic review of laparoscopic liver resection for hepatocellular carcinoma

AIM: To compare the surgical outcomes between laparoscopic liver resection (LLR) and open liver resection (OLR) as a curative treatment in patients with hepatocellular carcinoma (HCC).

METHODS: A PubMed database search was performed systematically to identify comparative studies of LLR vs OLR for HCC from 2000 to 2014. An extensive text word search was conducted, using combinations of search headings such as “laparoscopy”, “hepatectomy”, and “hepatocellular carcinoma”. A comparative study was also performed in our institution where we analysed surgical outcomes of 152 patients who underwent liver resection between January 2005 to December 2012, of which 42 underwent laparoscopic or hand-assisted laparoscopic resection and 110 underwent open resection.

RESULTS: Analysis of our own series and a review of 17 high-quality studies showed that LLR was superior to OLR in terms of short-term outcomes, as patients in the laparoscopic arm were found to have less intraoperative blood loss, less blood transfusions, and a shorter length of hospital stay. In our own series, both LLR and OLR groups were found to have similar overall survival (OS) rates, but disease-free survival (DFS) rates were higher in the laparoscopic arm.

CONCLUSION: LLR is associated with better short-term outcomes compared to OLR as a curative treatment for HCC. Long-term oncologic outcomes with regards to OS and DFS rates were found to be comparable in both groups. LLR is hence a safe and viable option for curative resection of 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.

Laparoscopic hepatectomy is associated with considerably less morbidity and a long-term survival similar to that of the open procedure in patients with hepatic colorectal metastases

BACKGROUND

Laparoscopic hepatectomy (LH) provides significant promising results when compared with open hepatectomy (OH). However, the oncologic outcome of LH for hepatic colorectal metastases (HCRM) remains controversial. The purpose of this study was to review the results of LH retrospectively and to compare them with those obtained using the conventional OH procedure for HCRM patients.

MATERIALS AND METHODS

Demographic details of 24 patients with pathologic determination of HCRM who underwent LH were reviewed retrospectively and weighed against the 25 HCRM patients chosen from the prospective OH database. Postsurgical benefits and 3-year outcomes of these 2 groups were compared.

RESULTS

The LH had a significantly less estimated blood loss (210 vs. 380 mL; P<0.01), less analgesic requirements (20.8% vs. 50.2%; P<0.001), shorter hospital stay (7.4 vs. 11.4 d; P<0.0001), and less postoperative complication rates (25% vs. 48%; P=0.02) compared with the OH approach. The operative time, positive surgical margin, and postoperative liver function changes were similar in the 2 groups. There were no significant differences between the 2 groups in tumor recurrence and the 3-year overall survival rate (24% vs. 30%; P=0.83), respectively.

CONCLUSIONS

LH is a practicable replacement for OH with probable advantages within the short-term outcomes for elected HCRM patients. Nevertheless, it remains an approach in advancement; in addition, randomized controlled trails and prolonged follow-up are necessary to verify its oncologic benefits and long-term survival.

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.

Laparoscopic vs. open liver resection for hepatocellular carcinoma of cirrhotic liver: a case-control study

BACKGROUND

Laparoscopic liver resection is considered a safe and feasible alternative to open surgery for malignant liver lesions. However, laparoscopic surgery in cirrhotic patients remains challenging. The aim of this retrospective case-control study was to compare morbidity, mortality, and long-term patient survival between laparoscopic liver resections (LLR) and open liver resections (OLR) for hepatocellular carcinoma (HCC) in patients with histologically proven cirrhosis.

METHODS

A total of 45 patients treated with LLR were matched by cause of cirrhosis, Child-Pugh score, type of surgical resection (subsegmentectomy, segmentectomy, and bisegmentectomy), tumor number, tumor size, and alpha-fetoprotein value with 45 patients treated with OLR. Pre-, intra-, and post-operative variables were compared between groups.

RESULTS

Compared with OLR, the LLR group displayed a significantly shorter operative time (140 vs. 180 min; p = 0.02), shorter hospital stay (7 vs. 12 days; p < 0.0001), and lower morbidity rate (20 vs. 45 % of patients; p = 0.01). A higher rate of R0 resection was observed in the LLR group than in the OLR group (95 vs. 85 %; p = 0.03). Postoperative ascites was more frequently observed in the OLR group (18 vs. 2 %; p = 0.01). Mortality, patient, and disease-free survival rates were similar between groups. The 1-, 5-, and 10-year survival rates were 88, 59, and 12 %, respectively, in the LLR group and 63, 44, and 22 % in the OLR group (p = 0.27).

CONCLUSIONS

Significantly shorter operative times, better resection margins, lower postoperative complications, and shorter hospital stay were observed in the LLR group compared with the OLR group. LLR and OLR have similar overall and disease-free survival rates in cirrhotic HCC patients.

The difficulty of laparoscopic liver resection

Grading of difficulty is needed for laparoscopic liver resection (LLR). Indications for LLR are expanding worldwide from minor to major resections, particularly in institutions having surgeons with advanced skills. If the degrees of surgical difficulty were defined, it would serve as a useful guide when introducing LLR and stepping up to the more advanced LLR. As no previous study has addressed the degrees of difficulty of various LLR procedures, we devised a practical scoring system for this purpose. We extracted the following five factors from preoperative information to score difficulty levels: (1) tumor location, (2) extent of liver resection, (3) tumor size, (4) proximity to major vessels, and (5) liver function. This difficulty index is comprised of the cumulative score for the five individual factors. There has not yet been a standard definition of difficulty. Our proposed scoring system might be a practical means of assessing the difficulty of LLR procedures. However, this system must be prospectively validated.

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.