Long-Term Implications of Unplanned Conversion During Laparoscopic Liver Resection for Hepatocellular Carcinoma

The State of Systematic Therapies in Clinic for Hepatobiliary Cancers

Hepatobiliary cancer (HBC) includes hepatocellular carcinoma and biliary tract carcinoma (cholangiocarcinoma and gallbladder carcinoma), and its morbidity and mortality are significantly correlated with disease stage. Surgery is the cornerstone of curative therapy for early stage of HBC. However, a large proportion of patients with HBC are diagnosed with advanced stage and can only receive systemic treatment. According to the results of clinical trials, the first-line and second-line treatment programs are constantly updated with the improvement of therapeutic effectiveness. In order to improve the therapeutic effect, reduce the occurrence of drug resistance, and reduce the adverse reactions of patients, the treatment of HBC has gradually developed from single-agent therapy to combination. The traditional therapeutic philosophy proposed that patients with advanced HBC are only amenable to systematic therapies. With some encouraging clinical trial results, the treatment concept has been revolutionized, and patients with advanced HBC who receive novel systemic combination therapies with multi-modality treatment (including surgery, transplant, TACE, HAIC, RT) have significantly improved survival time. This review summarizes the treatment options and the latest clinical advances of HBC in each stage and discusses future direction, in order to inform the development of more effective treatments for HBC.

Association between Unplanned Conversion and Patient Survival after Laparoscopic Liver Resection for Hepatocellular Carcinoma: A Propensity Score Matched Analysis

Unplanned conversion (UPC) is considered to be a predictor of poor postoperative outcomes. However, the effects of UPC on the survival of patients with hepatocellular carcinoma (HCC) remain controversial. The aim of this study is to compare the outcomes between patients who underwent laparoscopic liver resection (LLR) and those who underwent UPC for HCC. Among 1029 patients with HCC who underwent hepatectomy between 2004 and 2021, 251 were eligible for the study. Of 251 patients who underwent hepatectomy for HCC in PS segments, 29 (26.0%) required UPC, and 222 underwent LLR. After 1:5 PSM, 25 patients were selected for the UPC group and 125 for the LLR group. Blood loss, transfusion rate, hospital stay, and postoperative complication were higher in the UPC group. Regarding oncologic outcomes, although the 5-year overall survival rate was similar in both groups (p = 0.544), the recurrence-free survival rate was lower in the UPC group (p < 0.001). UPC was associated with poor short-term as well as inferior long-term outcomes compared with LLR for HCC in PS segments. Therefore, surgeons must carefully select patients and consider early conversion if unexpected bleeding occurs to maintain safety and oncologic outcomes.

Comparison of short-term outcomes between robotic and laparoscopic liver resection: a meta-analysis of propensity score-matched studies

OBJECTIVE

This meta-analysis aimed to compare short-term outcomes between robotic liver resection (RLR) and laparoscopic liver resection (LLR) using data collected from propensity score-matched studies.

METHODS

The PubMed, Cochrane Library, and Embase databases were searched to collect propensity score-matched studies comparing RLR and LLR. Relevant data were extracted and analyzed. Odds ratios (ORs) and standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated using fixed-effect or random-effect models. Meta-regression analysis was performed for primary outcome measures. Subgroup analyses and sensitivity analyses were performed for outcomes exhibiting high heterogeneity. Quality of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluation framework.

RESULTS

Twenty-two propensity score-matched studies were included to comprise 5272 patients (RLR group, 2422 cases; LLR group, 2850 cases). Intraoperative blood loss (SMD=-0.31 ml, 95% CI -0.48 to -0.14; P =0.0005), open conversion (OR=0.46, 95% CI 0.37-0.58; P <0.0001), and severe complications (OR=0.76, 95% CI 0.61-0.95; P =0.02) were significantly lower in the RLR group. Operation time, odds of use, and duration of Pringle maneuver, length of hospital stay, and odds of intraoperative blood transfusion, overall complications, R0 resection, reoperation, 30-day readmission, 30-day mortality, and 90-day mortality did not significantly differ between the groups. Further subgroup and sensitivity analyses suggested that the results were stable. Meta-regression analysis did not suggest a correlation between primary outcomes and study characteristics. The quality of evidence for the primary outcomes was medium or low, while that for the secondary outcomes was medium, low, or very low.

CONCLUSION

Although some short-term outcomes are similar between RLR and LLR, RLR is superior in terms of less blood loss and lower odds of open conversion and severe complications. In the future, RLR may become a safe and effective replacement for LLR.

Risk Factors and Long-Term Implications of Unplanned Conversion During Laparoscopic Liver Resection for Hepatocellular Carcinoma

Background: Laparoscopic liver resection (LLR) has become a widely used standardized operation for patients with hepatocellular carcinoma (HCC) in the field of hepatic surgery. However, the risk factors and long-term implications associated with unplanned conversion to an open procedure during the LLR have not been adequately studied. Methods: The study incorporated 96 patients with HCC. Risk factors of conversion and their prognosis were analyzed by comparing patients who successfully underwent LLR with those who required unplanned conversion. Results: In this study, the unplanned conversion rate for laparoscopic hepatectomy was 42.7%. Patients who underwent conversion had longer length of stay (8 versus 7 days, P < .001), longer operation time (297.73 versus 194.03 minutes, P = .000), a higher transfusion rate (29.3% versus 5.5%, P < .001), and more postoperative complications compared with patients who successfully underwent LLR. The two surgical maneuvers did not show substantial disparities in terms of total survival and disease-free survival rates. Risk factors of unplanned conversion contained tumor location (odds ratio [OR], 3.129; 95% confidence interval [CI]: 1.214-8.066; P = 0.018) and tumor size (OR, 2.652; 95% CI: 1.039-6.767; P = 0.041). Conclusions: The unplanned conversion during LLR for HCC was linked to unfavorable short-term prognosis, yet it did not influence long-term oncologic outcomes. Moreover, preoperative evaluation of tumor size and location may effectively reduce the probability of unplanned conversion during LLR.

Conversion of Minimally Invasive Liver Resection for HCC in Advanced Cirrhosis: Clinical Impact and Role of Difficulty Scoring Systems

BACKGROUND

Minimally invasive liver resections (MILRs) in cirrhosis are at risk of conversion since cirrhosis and complexity, which can be estimated by scoring systems, are both independent factors for. We aimed to investigate the consequence of conversion of MILR for hepatocellular carcinoma in advanced cirrhosis.

METHODS

After retrospective review, MILRs for HCC were divided into preserved liver function (Cohort-A) and advanced cirrhosis cohorts (Cohort-B). Completed and converted MILRs were compared (Compl-A vs. Conv-A and Compl-B vs. Conv-B); then, converted patients were compared (Conv-A vs. Conv-B) as whole cohorts and after stratification for MILR difficulty using Iwate criteria.

RESULTS

637 MILRs were studied (474 Cohort-A, 163 Cohort-B). Conv-A MILRs had worse outcomes than Compl-A: more blood loss; higher incidence of transfusions, morbidity, grade 2 complications, ascites, liver failure and longer hospitalization. Conv-B MILRs exhibited the same worse perioperative outcomes than Compl-B and also higher incidence of grade 1 complications. Conv-A and Conv-B outcomes of low difficulty MILRs resulted in similar perioperative outcomes, whereas the comparison of more difficult converted MILRs (intermediate/advanced/expert) resulted in several worse perioperative outcomes for patients with advanced cirrhosis. However, Conv-A and Conv-B outcomes were not significantly different in the whole cohort where "advanced/expert" MILRs were 33.1% and 5.5% in Cohort A and B.

CONCLUSIONS

Conversion in the setting of advanced cirrhosis can be associated with non-inferior outcomes compared to compensated cirrhosis, provided careful patient selection is applied (patients elected to low difficulty MILRs). Difficulty scoring systems may help in identifying the most appropriate candidates.

Laparoscopic versus open hepatectomy for large hepatocellular carcinoma: a single center propensity-score-matching comparative analysis of perioperative outcomes and long-term survival

BACKGROUND

Although the benefits of laparoscopic hepatectomy (LH) for hepatocellular carcinoma (HCC) in most circumstances are evident, the benefits for large HCC are contentious. This study aimed to compare the perioperative outcomes and survival after LH versus open hepatectomy (OH) in large HCC patients.

METHODS

An analysis of prospectively maintained database included 215 hepatectomies for large HCC (diameter ≥ 5 cm). The operative and survival outcomes were compared between the LH group (n = 109) and the OH group (n = 106). Propensity score matching (PSM) 1:1 included 70 patients in each group. The entire cohort multivariable analyses were performed to identify the factors associated with surgical complications and suboptimal recurrence-free survival (RFS).

RESULTS

After PSM, baseline characteristics and the extent of liver resection were similar in both groups. The LH group had a shorter hospital stay than the OH group (7 vs 9.5 days, p = 0.001). The R0 resection rate, complication rate, overall survival, and RFS were similar between the groups. The multivariate analyses revealed two independent factors predicting surgical complication (major resection; p < 0.001 and large volume blood loss; p = 0.042), and 3 independent factors predicting suboptimal RFS including R1 resection (p = 0.011), multifocal HCC (p = 0.005), and microvascular invasion (p = 0.001). LH was not associated with surgical complication and suboptimal RFS.

CONCLUSION

Our study highlights the benefits of LH by improving the perioperative outcomes, without long-term survival inferiority in selected large HCC patients compared with conventional OH. LH can be an attractive option for large HCC treatment.

Robotic liver resection for hepatocellular carcinoma: analysis of surgical margins and clinical outcomes from a western tertiary hepatobiliary center

This study was undertaken to determine surgical outcomes of patients undergoing robotic hepatectomy for hepatocellular carcinoma (HCC) and to investigate the correlation between tumor distance to margin and perioperative outcomes, as well as overall survival (OS). To our knowledge, this study represents the largest series of robotic liver resection for HCC in North America. We retrospectively analyzed 58 consecutive patients who underwent robotic liver resection for HCC. Patients were further stratified by tumor distance to margin (≤ 1 mm, 1.1-9.9 mm, ≥ 10 mm) and their clinical outcomes including OS were compared. A majority of patients attained a greater than 1 mm tumor distance to margin (81%). There were no differences in tumor size between patient cohorts who attained ≤ 1 mm, 1.1-9.9 mm, and ≥ 10 mm margins. There were no differences in pre-, intra-, and postoperative outcomes among the three cohorts. Cost variables of interest were also similar. OS was highest in the > 10 mm margin cohort, and this was statistically significant at 3 and 5 years. Robotic HCC resection was associated with adequate tumor distance to margin. Wide margins ≥ 10 mm are associated with the best OS.

A chronological review of 500 minimally invasive liver resections in a North American institution: overcoming stagnation and toward consolidation

BACKGROUND

Although interest in expanding the application of minimally invasive liver resection (MILR) is high the world over, most of the extensive experience in MILR has been reported from Far East Asia and Europe and its adoption in North America is limited. The aim of this study was to review the experience of MILR in a single North American institute over a 15-year period, highlighting both the obstacles encountered and strategies adopted to overcome the stagnation in its uptake.

METHODS

This study included 500 MILR cases between 2006 and 2020. Patient demographics, disease characteristics, surgical technique, and perioperative outcomes are summarized. The major hepatectomy rate and conversion rate were assessed according to case numbers (first 100, 101-300, and 301-500 cases) to assess chronological trends.

RESULTS

Of 500, 402 MILRs were done by pure laparoscopic (80.4%), 67 were hand assisted (13.4%), and 31 were robotic (6.2%). The majority (64%) of cases were performed for malignancy (n = 320; 100 Hepatocellular carcinoma, 153 Colorectal metastases, 27 Intrahepatic cholangiocarcinoma, and others, 40, 64%). A total of 71 cases were converted to open (14.2%). The annual case number gradually increased over the first few years; however, case numbers stayed around 30 between 2009 and 2017. In this period, despite accumulating MILR experience, open conversion rates increased despite no change in major hepatectomy rate. After this period of long-term stagnation, we introduced crucial changes in team composition and laparoscopic instrumentation. Our MILR case number and major hepatectomy rate thereafter increased significantly without increasing conversion or complication rates.

CONCLUSION

Our recovery from long-term stagnation by instituting key changes as detailed in this study could be used as a guidepost for programs that are contemplating transitioning their MILR program from minor to advanced resections. Establishing a formal MILR training model through proper mentorship/proctorship and building a dedicated MILR team would be imperative to this strategy.

The risk factors of intraoperative conversion during laparoscopic hepatectomy: a systematic review and meta-analysis

PURPOSE

Intraoperative conversion to laparotomy is a challenge during laparoscopic hepatectomy; however, the risk factors of conversion have been poorly elucidated.

METHODS

In this systematic review and meta-analysis, we computed pooled odds ratios (ORs) with 95% confidence intervals (CIs) for each risk factor and evaluated heterogeneity using a L'Abbe plot, Galbraith radial plot, Cochran's Q test, and I². An extended funnel plot was used to evaluate the robustness of the results of meta-analysis. Sensitivity analysis and subgroup analysis were performed to determine sources of heterogeneity. Egger's test and Begg's test were used to assess publication bias.

RESULTS

A total of 25 eligible studies were enrolled in the meta-analysis. Higher body mass index (OR 1.346, 95% CI 1.055-1.717), hypertension (OR 1.387, 95% CI 1.100-1.749), male sex (OR 1.278, 95% CI 1.072-1.523), cirrhosis (OR 1.378, 95% CI 1.062-1.788), major resection (OR 2.041, 95% CI 1.748-2.382), posterosuperior tumor location (OR 2.420, 95% CI 1.923-3.044), and larger tumor diameter (OR 1.618, 95% CI 1.270-2.061) were found to be significantly related to intraoperative conversion during laparoscopic hepatectomy. Malignant tumor (OR 1.253, 95% CI 0.970-1.619), higher American Society of Anesthesiologists stage (OR 1.186, 95% CI 0.863-1.631), multiple tumors (OR 1.273, 95% CI 0.866-1.871), and abdominal surgery history (OR 1.236, 95% CI 0.589-2.597) were not associated with conversion. A history of abdominal surgery showed significant heterogeneity with an I² of 80.8% (p < 0.001). Subgroup analysis indicated that heterogeneity was caused by the different number of patients among enrolled studies.

CONCLUSIONS

In this systematic review and meta-analysis, we identified a number of factors associated with intraoperative conversion during laparoscopic hepatectomy. Our findings can help patient risk evaluation to reduce the laparotomy conversion rate in laparoscopic hepatectomy.

Conversion to Open Radical or Partial Nephrectomy Associated with Unplanned Hospital Readmission After Attempted Minimally Invasive Approach

Introduction/Objectives: We endeavored to explore the rates of unplanned hospital readmission (UHR) in patients who underwent minimally invasive radical or partial nephrectomy who were subsequently converted to open surgery. Patients and Methods: The National Cancer Database (NCDB) was used for this study. Patients diagnosed with renal cancer and who had minimally invasive partial or radical nephrectomy from 2004 to 2016 were included in the study. Patients were categorized as converted or not converted to open surgery. UHR was the outcome of the study and was defined as UHR within 30 days of discharge. We conducted a one-to-one nearest-neighbor propensity-score matching using baseline clinical, tumor, and facility characteristics. To evaluate the relationship between conversion to open surgery and UHR, we conducted a multivariable logistic regression on the propensity-matched cohort, a propensity score-matched model without controlling for any covariate, and a propensity score-adjusted model, controlling for only the propensity score. Results: A total of 142,040 patients were identified, with a 2.98% conversion rate. There was an overall decrease in the rate of conversion to open surgery from 2010 (4.11%) to 2016 (2.43%). Laparoscopic radical nephrectomy remained a significant contributor to the rate of conversion (at least 50% per year). In the unmatched cohort, the UHR rate was higher among those who had a conversion to open surgery (n = 710, 0.52% versus n = 44, 1.04%; P < .001). Similarly, in the propensity score-matched cohort, the UHR rate was higher among those who had a conversion to open (n = 22, 0.52% versus n = 44, 1.04%; P = .007). After controlling for other factors, conversion to open remained independently associated with UHF. Conclusion: Conversion to open radical or partial nephrectomy from a minimally invasive approach is independently associated with an increased risk of 30-day UHR.

Risk factors and long-term implications of unplanned conversion during laparoscopic liver resection for hepatocellular carcinoma located in anterolateral liver segments

Purpose

The impact of conversion on perioperative and long-term oncologic outcomes is controversial. Thus, we compared these outcomes between laparoscopic (Lap), unplanned conversion (Conversion), and planned open (Open) liver resection for hepatocellular carcinoma (HCC) located in anterolateral (AL) liver segments and aimed to identify risk factors for unplanned conversion.

Methods

We retrospectively studied 374 patients (Lap, 299; Open, 62; Conversion, 13) who underwent liver resection for HCC located in AL segments between 2004 and 2018.

Results

Compared to the Lap group, the Conversion group showed greater values for operation time (p < 0.001), blood loss (p = 0.021), transfusion rate (p = 0.009), postoperative complication rate (p = 0.008), and hospital stay (p = 0.040), with a lower R0 resection rate (p < 0.001) and disease-free survival (p = 0.001). Compared with the Open group, the Conversion group had a longer operation time (p = 0.012) and greater blood loss (p = 0.024). Risk factors for unplanned conversion were large tumor size (odds ratio [OR], 1.35; 95% confidence interval [CI], 1.05-1.74; p = 0.020), multiple tumors (OR, 5.95; 95% CI, 1.45-24.39; p = 0.013), and other organ invasion (OR, 15.32; 95% CI, 1.80-130.59; p = 0.013).

Conclusion

In conclusion, patients who experienced unplanned conversion during LLR for HCC located in AL segments showed poor perioperative and long-term outcomes compared to those who underwent planned laparoscopic and open liver resection. Therefore, open liver resection should be considered in patients with risk factors for unplanned conversion.

How to minimize conversion to open surgery during laparoscopic liver resection: the point of view of hemostasis

It has been 30 years since laparoscopic liver resection was first introduced, and, in the beginning, wedge resection or nonanatomical liver resection was mainly performed. With the development of surgical techniques and instruments, many centers are currently performing major liver resections and even difficult anatomical liver resections such as segment VI, VII, and VIII and caudate segment. However, laparoscopic surgery has limitations in instrument manipulation, and due to the nature of liver resection surgery, massive bleeding may occur. Therefore, it is necessary to make efforts to minimize the bleeding and reduce the conversion to laparotomy due to bleeding.

Hepatocellular Carcinoma in 2021: An Exhaustive Update

Primary liver cancer is a challenging global health concern with an estimated more than a million persons to be affected annually by the year 2025. The commonest type is hepatocellular carcinoma (HCC), which has been increasing in incidence the world over, mostly due to chronic viral hepatitis B infection. In the last decade, paradigm changes in the etiology, understanding of molecular biology, and pathogenesis, including the role of gut microbiota; medical and surgical treatments, and outcome trends are notable. The application of omics-based technology has helped us unlock the molecular and immune landscape of HCC, through which novel targets for drug treatment such as immune-checkpoint inhibitors have been identified. Novel tools for the surveillance and diagnosis of HCC include protein-, genomics-, and composite algorithm-based clinical/biomarker panels. Magnetic resonance imaging-based novel techniques have improved HCC diagnosis through ancillary features that enhance classical criteria while positron emission tomography has shown value in prognostication. Identification of the role of gut microbiota in the causation and progression of HCC has opened areas for novel therapeutic research. A select group of patients still benefit from modified surgical and early interventional radiology treatments. Improvements in radiotherapy protocols, identification of parameters of futility among radiological interventions, and the emergence of novel first-line systemic therapies that include a combination of antiangiogenic and immune-checkpoint inhibitors have seen a paradigm change in progression-free and overall survival. The current review is aimed at providing exhaustive updates on the etiology, molecular biology, biomarker diagnosis, imaging, and recommended treatment options in patients with HCC.

Highs and lows in laparoscopic pancreaticoduodenectomy

INTRODUCTION

Laparoscopic pancreaticoduodenectomy (PD) is not widely accepted, and its use is controversial. Only correct patient selection and appropriate training of groups experienced in pancreatic surgery and laparoscopy will be able to establish its role and its hypothetical advantages.

METHODS

Out of 138 pancreatic surgeries performed in a two-year period (2017-2019), 23 were laparoscopic PD. We evaluate its efficacy and safety compared to 31 open PD.

RESULTS

There were no cases of B/C pancreatic or biliary fistula, nor any cases of delayed gastric emptying in the laparoscopic group, but hemorrhage required one reoperation. The conversion rate was 21% (five cases): one due to bleeding, and the remainder for non-progression. The converted patients showed no differences compared to those completed by laparoscopy. There were no differences between laparoscopic and open PD in surgical time, postoperative complications, reintervention rate, readmissions or mortality. R0 resection in tumor cases was 85% for laparoscopy and 69% in open surgery without statistical significance. The postoperative hospital stay was shorter in the laparoscopic PD group (eight vs. 15 days).

CONCLUSIONS

In a selected group, laparoscopic PD can be safely and effectively performed if carried out by groups who are experts in pancreatic surgery and advanced laparoscopy. The technique has the same postoperative results as open surgery and is oncologically adequate, with less hospital stay. Proper patient selection, a step-by-step program and a lax and early conversion prevents serious operating accidents.

Highs and lows in laparoscopic pancreaticoduodenectomy

INTRODUCTION

Laparoscopic pancreaticoduodenectomy (PD) is not widely accepted, and its use is controversial. Only correct patient selection and appropriate training of groups experienced in pancreatic surgery and laparoscopy will be able to establish its role and its hypothetical advantages METHODS: Out of 138 pancreatic surgeries performed in a two-year period (2017-2019), 23 were laparoscopic PD. We evaluate its efficacy and safety compared to 31 open PD.

RESULTS

There were no cases of B/C pancreatic or biliary fistula, nor any cases of delayed gastric emptying in the laparoscopic group, but hemorrhage required one reoperation. The conversion rate was 21% (five cases): one due to bleeding, and the remainder for non-progression. The converted patients showed no differences compared to those completed by laparoscopy. There were no differences between laparoscopic and open PD in surgical time, postoperative complications, reintervention rate, readmissions or mortality. R0 resection in tumor cases was 85% for laparoscopy and 69% in open surgery without statistical significance. The postoperative hospital stay was shorter in the laparoscopic PD group (eight vs. 15 days).

CONCLUSIONS

In a selected group, laparoscopic PD can be safely and effectively performed if carried out by groups who are experts in pancreatic surgery and advanced laparoscopy. The technique has the same postoperative results as open surgery and is oncologically adequate, with less hospital stay. Proper patient selection, a step-by-step program and a lax and early conversion prevents serious operating accidents.

Pure laparoscopic right hepatectomy: A risk score for conversion for the paradigm of difficult laparoscopic liver resections. A single centre case series

BACKGROUND

Converted laparoscopic hepatectomies are known to lose some advantages of the minimally-invasiveness, and factors are identified to predict patients at risk. Specific evidence for laparoscopic right hepatectomy is expected of usefulness in clinical practice, given its technical peculiarities. The purpose of the study was the identification of risk factors and the development of a risk score for conversion of laparoscopic right hepatectomy.

MATERIALS AND METHODS

Laparoscopic right hepatectomy performed at a single hepatobiliary surgical center were analyzed. The cohort was split in half to obtain a derivation and a validation set. Risk factors for conversion were identified by uni- and multivariable analysis. A "conversion risk score" was built assigning each factor 1 point and comparing the score with the conversion status for each patient. The accuracy was assessed by the area-under-the-receiver-operator-characteristic-curve.

RESULTS

Among 130 operations, 22 were converted (16.9%). Reasons were: 45.5% oncologic inadequacy, 31.8% bleeding, 9.1% adhesions, 9.1% biliostasis, 4.5% anaesthesiological problems. Independent risk factors for conversion were: previous laparoscopic liver surgery (Hazard Ratio 4.9, p 0.011), preoperative chemotherapy ( Hazard Ratio 6.2, p 0.031), malignant diagnosis (Hazard Ratio 3.3, p 0.037), closeness to hepatocaval confluence or inferior vena cava (Hazard Ratio 4.1, p 0.029), tumor volume (Hazard Ratio 2.9, p 0.024). Conversion rates correlated positively with the score, raising from 0 to 100% when the score increased from 0 to 5 (Spearman: p 0.032 in the derivation set, p 0.020 in the validation set). The risk of conversion showed a sharp increase passing from class 3 to 4, reaching a probability estimated between 60 and 71.4%. The score showed good accuracy (area-under-the-receiver-operator-characteristic-curve 0.82).

CONCLUSION

Specific risk factors for conversion are identified for laparoscopic right hepatectomy. This score may help in standardizing the choice of a pure laparoscopic or open approach for such challenging resections.

A falciform ligament flap surface sealing technique for laparoscopic and robotic-assisted liver surgery

Whether sealing the hepatic resection surface after liver surgery decreases morbidity is still unclear. Nevertheless, various methods and materials are currently in use for this procedure. Here, we describe our experience with a simple technique using a mobilized falciform ligament flap in minimally invasive liver surgery (MILS). We retrospectively analyzed the charts from 46 patients who received minor MILS between 2011 and 2019 from the same surgical team in a university hospital setting in Germany. Twenty-four patients underwent laparoscopic liver resection, and 22 patients received robotic-assisted liver resection. Sixteen patients in the laparoscopic group and fourteen in the robotic group received a falciform ligament flap (FLF) to cover the resection surface after liver surgery. Our cohort was thus divided into two groups: laparoscopic and robotic patients with (MILS + FLF) and without an FLF (MILS-FLF). Twenty-eight patients (60.9%) in our cohort were male. The overall mean age was 56.8 years (SD 16.8). The mean operating time was 249 min in the MILS + FLF group vs. 235 min in the MILS-FLF group (p = 0.682). The mean blood loss was 301 ml in the MILS + FLF group vs. 318 ml in the MILS-FLF group (p = 0.859). Overall morbidity was 3.3% in the MILS + FLF group vs. 18.8% in the MILS-FLF group (p = 0.114). One patient in the MILS-FLF group (overall 2.2%), who underwent robotic liver surgery, developed bile leakage, but this did not occur in the MILS + FLF group. Covering the resection surface of the liver after minor minimally invasive liver resection with an FLF is a simple and cost-effective technique that does not prolong surgical time or negatively affect other perioperative parameters. In fact, it is a safe add-on step during MILS that may reduce postoperative morbidity. Further studies with larger cohorts will be needed to substantiate our proof of concept and results.

Advances in resection and transplantation for hepatocellular carcinoma

It would be impossible to summarise all of the significant developments in the surgical management of hepatocellular carcinoma (HCC), even just over the past year, in a manuscript of this scope. Thus, we have selected topics for discussion that are the subject of current controversy and have attempted to present balanced points of view. Hepatic resection and transplantation are both mature modalities, and for the most part technical advances and improvements in candidate selection are incremental. The ability to readily cure hepatitis C stands out as the most impactful development in the field over recent years, especially in Western countries where hepatitis C has long been the chief aetiology underlying HCC and a predictor of poor outcomes after surgery, but its full implications remain to be clarified. The rising incidence of non-alcoholic steatohepatitis-related HCC and what it means with regard to surgical HCC management is an area of great current interest. With advancing technology, non-surgical locoregional treatments are gaining increasing application as potentially curative therapies. In addition, the advances in molecular and genomic assessment of HCC hold promise for personalising treatment and prognostication. The possible role of immunotherapy as an adjuvant to resection is being aggressively investigated. While liver surgery maintains an important role, the care of patients with HCC is more and more a team effort and needs to take place in the context of a well-integrated interdisciplinary programme to achieve the best outcomes for patients.

Unplanned conversion during minimally invasive liver resection for hepatocellular carcinoma: risk factors and surgical outcomes

Purpose

Unplanned conversion is sometimes necessary during minimally invasive liver resection (MILR) of hepatocellular carcinoma (HCC). The aims of this study were to compare surgical outcomes of planned MILR and unplanned conversion and to investigate the risk factors after unplanned conversion.

Methods

We retrospectively analyzed 286 patients who underwent MILR with HCC from January 2006 to December 2017. All patients were divided into a MILR group and an unplanned conversion group. The clinicopathologic characteristics and outcomes were compared between the 2 groups. In addition, surgical outcomes in the conversion group were compared with the planned open surgery group (n = 505). Risk factors for unplanned conversion were analyzed.

Results

Of the 286 patients who underwent MILR, 18 patients (6.7%) had unplanned conversion during surgery. The unplanned conversion group showed statistically more blood loss, higher transfusion rate and postoperative complication rate, and longer hospital stay compared to the MILR group, whereas no such difference was observed in comparison with the planned open surgery group. There were no significant differences in overall and disease-free survival among 3 groups. The right-sided sectionectomy (right anterior and posterior sectionectomy), central bisectionectomy and tumor size were risk factors of unplanned conversion.

Conclusion

Unplanned conversion during MILR for HCC was associated with poor perioperative outcomes, but it did not affect long-term oncologic outcomes in our study. In addition, when planning right-sided sectionectomy or central bisectionectomy for a large tumor (more than 5 cm), we should recommend open surgery or MILR with an informed consent for unplanned open conversions.

A meta-analysis of randomized controlled trials comparing laparoscopic vs open pancreaticoduodenectomy

BACKGROUND

Recent randomized controlled trials (RCTs) reported conflicting results regarding the safety of laparoscopic pancreaticoduodenectomy (LPD). The aim of this study was to perform a meta-analysis of the available RCTs concerning the short-term outcomes of LPD versus open pancreaticoduodenectomy (OPD).

METHODS

The Cochrane Central Register of Controlled Trials, MEDLINE (through PubMed), EMBASE, Scopus databases and ClinicalTrials.gov register were searched. Only RCTs published up to February 2019 were eligible for inclusion. Random-effect models were used to summarize the relative risks (RR) and mean differences.

RESULTS

3 RCTs were identified, including a total number of 114 and 110 patients who underwent LPD and OPD, respectively. The rate of major postoperative complications (Clavien-Dindo ≥3) was 29% in LPD vs 31% in OPD group (RR 0.80 (95% CI: 0.36-1.79); p = 0.592). Complication-related mortality occurred in 5% (LPD) vs 4% (OPD) patients (RR 1.22 (95% CI: 0.19-8.02); p = 0.841). LPD was significantly associated with longer operative time [95 min (95% CI: 24-167; p = 0.009)] and lower perioperative blood loss [-151 ml (95% CI: 169-133; p < 0.001)].

CONCLUSIONS

There are no statistically significant differences between LPD and OPD in terms of postoperative complications and mortality. However, these findings should be interpreted with caution due to high clinical and statistical heterogeneity of pooled data. Further studies with different outcome measures are needed to clarify the future of LPD.