Liver Surgery for Hepatocellular Carcinoma: Laparoscopic versus Open Approach

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.

Surgical Resection: Old Dog, Any New Tricks?

Patients with hepatocellular carcinoma (HCC) have many treatment options. For patients with surgical indication, consideration of future liver remnant and the surgical complexity of the procedure is essential. A new 3-level complexity classification categorizing 11 liver resection procedures predicts surgical complexity and postoperative morbidity better than reported classifications. Preoperative portal vein embolization can mitigate the risk of hepatic insufficiency. For small HCCs, both liver resection and ablation are effective. New medical treatment options are promising and perioperative use of these drugs may further improve outcomes for patients undergoing liver resection and lead to changes in current treatment guidelines.

Laparoscopic versus open major liver resection for hepatocellular carcinoma: systematic review and meta-analysis of comparative cohort studies

Background

The application of laparoscopic liver resection (LLR) has expanded rapidly in recent decades. Although multiple authors have reported LLR shows improved safety and efficacy in treating hepatocellular carcinoma (HCC) compared with open liver resection (OLR), laparoscopic (LMLR) and open (OMLR) major liver resections for HCC treatment remain inadequately evaluated. This work aimed to test the hypothesis that LMLR is safer and more effective than OMLR for HCC.

Methods

Comparative cohort and registry studies on LMLR and OMLR, searched in PubMed, the Science Citation Index, EMBASE, and the Cochrane Library, and published before March 31, 2018, were collected systematically and meta-analyzed. Fixed- and random-effects models were employed for generating pooled estimates. Heterogeneity was assessed by the Q-statistic.

Results

Nine studies (1173 patients) were included. Although the pooled data showed operation time was markedly increased for LMLR in comparison with OMLR (weighted mean difference [WMD] 74.1, 95% CI 35.1 to 113.1, P = 0.0002), blood loss was reduced (WMD = − 107.4, 95% CI − 179.0 to − 35.7, P = 0.003), postoperative morbidity was lower (odds ratio [OR] 0.47, 95% CI 0.35 to 0.63, P <  0.0001), and hospital stay was shorter (WMD = − 3.27, 95% CI − 4.72 to − 1.81, P <  0.0001) in the LMLR group. Although 1-year disease-free survival (DFS) was increased in patients administered LMLR (OR = 1.55, 95% CI 1.04 to 2.31, P = 0.03), other 1-, 3-, and 5-year survival outcomes (overall survival [OS] and/or DFS) were comparable in both groups.

Conclusions

Compared with OMLR, LMLR has short-term clinical advantages, including reduced blood loss, lower postsurgical morbidity, and shorter hospital stay in HCC, despite its longer operative time. Long-term oncological outcomes were comparable in both groups.

Our experience of repeat laparoscopic liver resection in patients with recurrent hepatocellular carcinoma

BACKGROUND

Repeat liver resection is an effective treatment approach for patients with recurrent hepatocellular cell carcinoma (HCC). However, the surgical feasibility and oncological significance of repeat laparoscopic liver resection (r-LLR) remain unproven. This study evaluates and compares the clinical outcomes of non-anatomic r-LLR applied towards recurrent HCC, with those of primary LLR (p-LLR) for primary HCC.

METHODS

This retrospective study reports 104 patients with HCC, treated with LLR between 2014 and 2018. Twenty eight of these patients underwent r-LLR for recurrent HCC. The clinical and surgical variables were reviewed for all cases.

RESULTS

The analysis was limited to non-anatomic resection across both groups (r-LLR: 89% (25/28) vs. p-LLR: 80% (61/76)). There were no statistically significant differences about patient background between the two groups, with the exception of Child-Pugh classification. r-LLR surgical techniques included single-site laparoscopic adhesiolysis (32%, 8/25), Pringle maneuver (8%, 2/25), and crush-clamp method using BiClamp for hepatic parenchymal transection (72%, 18/25). No severe postoperative complications were observed in the r-LLR group. Postoperative hospital stays and procedure-related postoperative survival were similar for both groups.

CONCLUSIONS

Non-anatomical r-LLR renders comparable surgical and oncological outcomes. Our data suggest that non-anatomical r-LLR is a safe and feasible therapeutic approach to recurrent HCC.

Long-term perioperative outcomes of pure laparoscopic liver resection versus open liver resection for hepatocellular carcinoma: a retrospective study

BACKGROUND

Laparoscopic treatment for hepatocellular carcinoma (HCC) has increased. We retrospectively compared the perioperative and long-term oncological outcomes of laparoscopic liver resection (LLR) with those of open liver resection (OLR) for hepatocellular carcinoma (HCC) in well-matched patient groups using propensity score matching (PSM).

METHODS

We reviewed medical records of patients with HCC who underwent liver resection between July 2007 and April 2016 at our center. In total, 2335 patients were included in this study and divided into LLR (n = 264) and OLR (n = 2071) groups. For group comparisons, 1:2 PSM was used with covariates of baseline characteristics, including tumor characteristics and surgical liver resection procedures.

RESULTS

After PSM, there were 217 and 434 patients in the LLR and OLR groups, respectively. The LLR group had shorter hospital stays (8.9 vs. 14.8 days; P < 0.001) and lower postoperative morbidity (6.5% vs. 12.0%; P = 0.022). The 1-, 3-, and 5-year overall survival rates were 98.1%, 87.0%, and 78.6%, respectively, for the LLR group, and 98.3%, 90.8%, and 84.3%, respectively, for the OLR group (P = 0.570). The 1-, 3-, and 5-year disease-free survival rates were 81.0%, 62.0%, and 49.1%, respectively, for the LLR group, and 85.3%, 64.7%, and 56.2%, respectively, for the OLR group (P = 0.563).

CONCLUSIONS

Long-term oncological outcomes were comparable between LLR and OLR for selected patients. LLR was associated with multiple benefits, even for selected patients with cirrhosis who underwent major hepatectomy. LLR for HCC performed by an experienced surgeon could be considered a safe and feasible alternative to OLR for selected patients.

A Systematic Review and Meta-Analysis Comparing the Short- and Long-Term Outcomes for Laparoscopic and Open Liver Resections for Hepatocellular Carcinoma: Updated Results from the European Guidelines Meeting on Laparoscopic Liver Surgery, Southampton, UK, 2017

BACKGROUND

The laparoscopic approach to liver resection has experienced exponential growth in recent years; however, its application is still under debate and objective, evidence-based guidelines for its safe future progression are needed.

OBJECTIVE

The aim of this study was to perform a systematic review and meta-analysis comparing the short- and long-term outcomes of laparoscopic and open liver resections for hepatocellular carcinoma (HCC).

METHODS

To identify all the comparative manuscripts reporting on laparoscopic and open liver resection for HCC, all published English-language studies with more than 10 cases were screened. In addition to the primary meta-analysis, four specific subgroup analyses were performed on patients with Child-Pugh A cirrhosis, resections for solitary tumors, and those undergoing minor and major resections. The quality of the studies was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) methodology and the Newcastle-Ottawa Scale.

RESULTS

From the initial 361 manuscripts, 28 were included in the meta-analysis. Five of these 28 manuscripts were specific to patients with Child-Pugh A cirrhosis (321 cases), 11 focused on solitary tumors (1003 cases), 16 focused on minor resections (1286 cases), and 3 focused on major resections (164 cases). Three manuscripts compared 1079 cases but could not be assigned to any of the above subanalyses. In general terms, short-term outcomes were favorable when using a laparoscopic approach, especially in minor resections. The only advantage seen with an open approach was reduced operative time during major liver resections. No differences in long-term outcomes were observed between the approaches.

CONCLUSIONS

Laparoscopic liver resection for HCC is feasible and offers improved short-term outcomes, with comparable long-term outcomes as the open approach.

Meta-analysis of short- and long-term outcomes after pure laparoscopic versus open liver surgery in hepatocellular carcinoma patients

Background

The advantages of laparoscopy are widely known. Nevertheless, its legitimacy in liver surgery is often questioned because of the uncertain value associated with minimally invasive methods. Our main goal was to compare the outcomes of pure laparoscopic (LLR) and open liver resection (OLR) in patients with hepatocellular carcinoma.

Methods

We searched EMBASE, MEDLINE, Web of Science, and The Cochrane Library databases to find eligible studies. The most recent search was performed on December 1, 2017. Studies were regarded as suitable if they reported morbidity in patients undergoing LLR versus OLR. Extracted data were pooled and subsequently used in a meta-analysis with a random-effects model. Clinical applicability of results was evaluated using predictive intervals. Review was reported following the PRISMA guidelines.

Results

From 2085 articles, forty-three studies (N = 5100 patients) were included in the meta-analysis. Our findings showed that LLR had lower overall morbidity than OLR (15.59% vs. 29.88%, p < 0.001). Moreover, major morbidity was reduced in the LLR group (3.78% vs. 8.69%, p < 0.001). There were no differences between groups in terms of mortality (1.58% vs. 2.96%, p = 0.05) and both 3- and 5-year overall survival (68.97% vs. 68.12%, p = 0.41) and disease-free survival (46.57% vs. 44.84%, p = 0.46).

Conclusions

The meta-analysis showed that LLR is beneficial in terms of overall morbidity and non-procedure-specific complications. That being said, these results are based on non-randomized trials. For these reasons, we are calling for randomization in upcoming studies. Systematic review registration: PROSPERO registration number CRD42018084576.

Electronic supplementary material

The online version of this article (10.1007/s00464-018-6431-6) contains supplementary material, which is available to authorized users.

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.

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.

Laparoscopic vs open hepatectomy for hepatocellular carcinoma in patients with cirrhosis: A meta-analysis of the long-term survival outcomes

BACKGROUND

In patients with hepatocellular carcinoma (HCC) and cirrhosis, laparoscopic hepatectomy (LH) confers short-term benefits over open hepatectomy (OH) but the long-term outcomes of this procedure are unclear. This systematic review aims to compare the long-term survival outcomes of LH and OH for patients with HCC and underlying cirrhosis.

METHODS

EMBASE, MEDLINE and Scopus databases were searched from date of inception to 7th October 2016. Controlled clinical studies comparing LH to OH for HCC in cirrhotic patients, which reported long-term overall and disease-free survival were included. The studies were evaluated using the MOOSE guidelines and Newcastle-Ottawa Scale. Data were extracted and analysed using a fixed-effects model.

RESULTS

Five non-randomised, retrospective observational studies representing 888 patients were included. LH was associated with significantly lower tumour recurrence [OR: 0.65, 95% CI: 0.48, 0.89]. LH conferred greater overall survival at 1- [HR: 0.41, 95% CI: 0.25, 0.68], 3- [HR: 0.63, 95% CI: 0.46, 0.87] and 5-years [HR: 0.60, 95% CI: 0.45, 0.80]. With LH, there was higher disease-free survival at 1-year [HR: 0.71, 95% CI: 0.53, 0.96], but not at 3- [HR: 0.89, 95% CI: 0.70, 1.14]; and 5-years [HR: 0.85, 95% CI: 0.70, 1.04].

CONCLUSIONS

Laparoscopic surgery is associated with comparable postoperative and survival outcomes in patients with HCC and underlying cirrhosis. With careful selection of patients, this approach is safe, feasible and advantageous.

Laparoscopic liver resections for hepatocellular carcinoma. Can we extend the surgical indication in cirrhotic patients?

BACKGROUND

Evidence on the value of laparoscopic liver resections (LLR) for hepatocellular carcinoma (HCC) and severe cirrhosis is still lacking. The aim of this study is to assess surgical and oncological outcomes of LLR in cirrhotic HCC patients.

METHODS

The analysis included 403 LLR for HCC from seven European centres. 333 cirrhotic and 70 non-cirrhotic patients were compared. A matched comparison was performed between 100 Child-Pugh A and 25 Child-Pugh B patients.

RESULTS

There was no difference in blood loss (250 vs. 250 mL, p 0.465) and morbidity (28.6 vs. 26.4%, p 0.473) between cirrhotics and non-cirrhotics, and liver-specific complications were similar (12.8 vs. 12%, p 0.924). The sub-analysis revealed similar perioperative outcomes in either Child-Pugh A or B patients. Noteworthy, ascitis (11 vs. 12%, p 0.562) and liver failure (3 vs. 4%, p 0.595) were not different. ASA score (OR 1.76, p 0.034) and conversion (OR 2.99, p 0.019) were risk factors for major morbidity. Despite lower recurrence-free survival in cirrhotics (43 vs. 55 months, p 0.034), overall survival was similar to non-cirrhotic patients (84 vs. 76.5, p 0.598).

CONCLUSION

LLR for HCC appear equally safe in cirrhotic and non-cirrhotic patients, and the advantages can be witnessed in those with advanced cirrhosis. Severe comorbidities and conversion should be considered risk factors for complications-rather than the severity of cirrhosis and portal hypertension-when liver resection is performed laparoscopically. Such results may be of great interest to liver surgeons and hepatologists when deciding on the management of HCC within cirrhosis.

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.

Laparoscopic and robotic approach for hepatocellular carcinoma-state of the art

Hepatocellular carcinoma (HCC) is the sixth most common malignant tumor worldwide and the most common primary liver cancer, in over 80% of cases HCC grown on a cirrhotic liver. Laparoscopic liver resection (LLR) is now worldwide accepted considering the excellent results shown. Minimally invasive surgical approach for HCC is increasing continuously and in specialized centers seems to become the first-line approach for those patients. The aim of this review presents and discusses state of the art in the laparoscopic and robotic surgical treatment of HCC. An electronic search was performed to identify all studies dealing with HCC resected with laparoscopy or robotic approach. Indications for laparoscopic resection, robotic assisted and totally robotic resection of HCC will be doubtless increased in future years. LLR and robotic approach for HCC is safe and feasible.

Technical feasibility and safety of laparoscopic right hepatectomy for hepatocellular carcinoma following sequential TACE-PVE: a comparative study

BACKGROUND

Major liver resection for hepatocellular carcinoma (HCC) ideally involves preoperative portal venous embolization (PVE) coupled with preoperative transarterial chemoembolization (TACE) to improve postoperative course and oncological results. Laparoscopic right hepatectomy (RH) following sequential TACE-PVE for HCC, although challenging, may help improve both immediate and long-term patient outcomes. This study is the first to describe and compare laparoscopic to open RH following sequential TACE-PVE for HCC in terms of feasibility, safety, and patient outcomes.

STUDY DESIGN

All patients who underwent laparoscopic RH following successful TACE-PVE sequence (video provided) were retrospectively reviewed from a prospective database maintained at our center. Preoperative characteristics, operative data, and postoperative outcomes were analyzed and compared with those of patients who underwent open RH after TACE-PVE sequence during the same period.

RESULTS

The laparoscopic and open RH groups each included 16 patients. F3 or F4 fibrosis was present in 81 % of patients. The conversion rate was 25 %. The 90-day postoperative complication rate was 25 % in the laparoscopic group versus 50 % in the open group (p = 0.27). The incidence of postoperative liver failure grade B was higher in the open group than in the laparoscopic group (5 vs. 0 patients, p = 0.043). Severe complications, Clavien grade ≥ IIIb, only occurred in the open group and included one postoperative death. Hospital stay was significantly shorter in the laparoscopic group than in the open group (7 vs. 12 days, p = 0.001). R0 resection was accomplished in 93.8 % of laparoscopic patients.

CONCLUSION

Laparoscopic approach seems technically feasible and safe. This modern approach may optimize the surgical strategy in the future of HCC management.

Anticancer effect of 20(S)-ginsenoside Rh2 on HepG2 liver carcinoma cells: Activating GSK-3β and degrading β-catenin

20(S)-ginsenoside Rh2 [(S)Rh2] possesses potential to prevent cancer in vitro as well as in vivo, but the underlying mechanism is still unknown. First, we infected HepG2 cells with lentivirus which carries β‑catenin. We detected the pharmacological effects of (S)Rh2 on HepG2 and HepG2‑β‑catenin cells and found that the IC50 of (S)Rh2 exposure on HepG2-β-catenin cells was higher than HepG2 cells. Flow cytometry (FCM) indicated that (S)Rh2 could be arrested in G0/G1 phase and induce early apoptosis in HepG2 and HepG2‑β‑catenin cells. Second, ELISA kit was used to check the activity of glycogen synthase kinase‑3β (GSK‑3β), which was upregulated by (S)Rh2. GSK‑3β inhibitor BIO, was used to verify that (S)Rh2 activated GSK‑3β. PCR and western blotting results indicated that (S)Rh2 could degrade the expression of β‑catenin, which combined with TCF in the nucleus and activate transcription of Wnt target genes, such as Bax, Bcl‑2, cyclin D1, MMP3, which were checked by chromatin immunoprecipitation (ChIP), PCR and western blotting. The results showed that the expression of Bax mRNA and proteins increased, while the cyclin D1, Bcl‑2, MMP3 mRNA and proteins were downregulated in HepG2 and HepG2‑β‑catenin cells which was induced by (S)Rh2. By contrast, with the HepG2-β-catenin + (S)Rh2 group, the expression of other mRNA and proteins in HepG2 + (S)Rh2 group changed significantly. In vivo, experiments were performed using a nude mouse xenograft model to investigate the (S)Rh2 effect. So these results suggested that (S)Rh2 could suppress proliferation, promote apoptosis and inhibit metastasis of HepG2, decrease weight of tumor by downregulating β‑catenin through activating GSK‑3β and the pharmacological effect of (S)Rh2 on HepG2 cells might be weakened by overexpression of β‑catenin.

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 liver resection: Experience based guidelines

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

Blood loss and outcomes after resection of colorectal liver metastases

BACKGROUND

The influence of intraoperative blood loss (IBL) on long-term outcomes of patients undergoing liver resection for colorectal cancer liver metastases (CRLM) remains not well defined.

MATERIALS AND METHODS

A total of 433 patients who underwent curative-intent hepatic resection for CRLM between 2000 and 2013 at Johns Hopkins were identified. Demographics, IBL data, and long-term outcomes were collected and analyzed. Clinicopathologic predictors of IBL and the association of IBL and outcomes were assessed.

RESULTS

The median patient age was 54 y (interquartile range, 44-64), most patients were male (58.9%; n = 255). At surgery, the median IBL was 400 mL (range, 10-5100 mL). Two-hundred eighty-seven patients (66.3%) had an IBL of >250 mL. Factors associated with increased IBL (>250 mL) on multivariate analysis were male sex (odds ratio [OR], 2.62; 95% confidence interval [CI], 1.68-4.09; P < 0.001), tumor size >3 cm (OR, 1.88; 95% CI, 1.18-2.99; P = 0.008), and major hepatic resection (OR, 3.08; 95% CI, 1.92-4.92; P < 0.001). At a median follow-up time of 30.6 mo, the median survival times were 70.5, 56.4, and 36.9 mo for IBL <250, 250-1000, and >1000 mL, respectively (P = 0.004). IBL >250 mL remained an independent prognostic factor of overall survival in multivariate analysis (hazard ratio, 1.41; 95% CI, 1.01-1.97; P = 0.04) after adjusting for other factors including the receipt of blood transfusion.

CONCLUSIONS

The magnitude of IBL during CRLM resection was related to biologic characteristics of the tumor and the extent of surgery. Increased IBL during CRLM resection was an independent prognostic factor for worse patient survival. Furthermore, a dose-response relationship between increasing IBL and worsening survival was evident.

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.

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.

Laparoscopic versus open liver resection for hepatocellular carcinoma: Case-matched study with propensity score matching

BACKGROUND & AIMS

Laparoscopic liver resection has gained wide acceptance and is established as a safe alternative to open liver resection. Until now, there is no prospective randomized comparative study between laparoscopic and open liver resection. Previous comparative studies reported minor resections for peripheral tumors, and enrolled small numbers of patients. Moreover, few reported the long term outcomes. The aim of this study is to compare perioperative and long term outcomes of laparoscopic versus open liver resection for hepatocellular carcinoma between two matched groups.

METHODS

389 patients underwent liver resection for hepatocellular carcinoma during the period between 2004 and 2013. To overcome selection bias, we performed 1:1 match using propensity score matching between laparoscopic and open liver resection.

RESULTS

After propensity score matching, 88 patients were included in each group. Laparoscopic group had shorter hospital stay (8 vs. 10 days, p⩽0.001), and lower postoperative morbidity (12.5% vs. 20.4%, p=0.042). The 1-, 3- and 5-year overall survivals were 91.6%, 87.5%, and 76.4%, for laparoscopic group, and were 93.1%, 87.8%, and 73.2%, for open group (p=0.944). The 1-, 3- and 5-year disease free survivals were 69.7%, 52%, and 44.2%, for laparoscopic group, and 74.7%, 49.5%, 41.2%, for open group (p=0.944).

CONCLUSIONS

Our study showed comparative perioperative and long term outcomes between both groups, providing evidence regarding the safety and efficacy of laparoscopic liver resection for hepatocellular carcinoma.

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.

A propensity score-matched case-control comparative study of laparoscopic and open liver resection for hepatocellular carcinoma

BACKGROUND

The aim of this study was to compare the perioperative and long-term oncologic outcomes of laparoscopic liver resection (LLR) and open liver resection (OLR) for single hepatocellular carcinoma (HCC) in case-controlled patient groups using the propensity score.

PATIENTS AND METHODS

Between January 2005 and February 2013, 292 patients underwent surgical resection for HCC. Of these, 202 patients who underwent surgical resection for initial treatment for a single mass were enrolled. These patients were divided into two groups according to the method of operation: the Lap group (patients who underwent LLR) and the Open group (patients who underwent OLR). To correct different demographic and clinical factors in the two groups, propensity score matching was used at a 1:1 ratio, and, finally, 102 patients were enrolled in this study, 51 patients in each group. Preoperative characteristics, perioperative results, and long-term results were retrospectively analyzed based on the prospectively recorded database.

RESULTS

Preoperative baseline variables were well balanced in both groups. There were no differences of extent of surgery and rate of anatomical resection between the two groups. With the exception of a shorter postoperative hospital stay in the Lap group than that of the Open group (8.2 days versus 12.3 days; P=.004), there were no significant differences in perioperative, pathological, and long-term outcomes. The 5-year overall survival rates were 80.1% in the Lap group and 85.7% in the Open group, respectively (P=.173). The 5-year disease-free survival rates were 67.8% in the Lap group and 54.8% in the Open group, respectively (P=.519).

CONCLUSIONS

LLR for HCC is safe, and long-term oncologic outcomes in selected patients were comparable to those who underwent OLR.

Laparoscopic versus open liver resection for hepatocellular carcinoma in posterosuperior segments

BACKGROUND

Traditional open liver resection remains the classic procedure for hepatocellular carcinoma (HCC) located in the posterosuperior segments of the liver (segments I, IVa, VII, and VIII). This study compared the perioperative and oncologic results for laparoscopic versus open liver resection of HCC located in the posterosuperior segments, especially in patients with cirrhosis.

METHODS

This study included 41 patients who underwent laparoscopic liver resection (LLR) and 86 who underwent open liver resection (OLR) for HCC in the posterosuperior segments between January 1, 2010, and December 31, 2012. There perioperative course and oncologic outcomes were retrospectively evaluated.

RESULTS

There were no significant differences between the LLR and OLR groups in length of operation (242.41 ± 73.69 vs. 235.38 ± 65.80 min), transfusion rate (7.3 vs. 14.0 %), R0 resection rate (100 vs. 97.7 %), or tumor size (4.22 ± 2.05 vs. 4.30 ± 1.49 cm). In contrast, postoperative hospital stay (9.44 ± 2.72 vs. 14.53 ± 6.03 days) was significantly shorter, and postoperative complication rates (17.1 vs. 37.2 %) and intraoperative blood loss (272.20 ± 170.86 vs. 450.12 ± 344.70 mL) significantly lower in the LLR than in the OLR group. In addition, there was no significant difference between the two groups (LLR vs. OLR) regarding 1-year overall survival rate (95.1 vs. 89.5 %), 3-year overall survival rate (78 vs. 76.7 %,), 1-year disease-free survival rate (87.8 vs. 82.6 %,), and 3-year disease-free survival rate (70.7 vs. 68.6 %).

CONCLUSIONS

LLR for selected patients with HCC in the posterosuperior segments may offer the same oncologic outcomes as conventional procedures, while being associated with such advantages as lower blood loss, fewer postoperative complications, and shorter hospital stay.

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

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

Bleeding control during laparoscopic liver resection: a review of literature

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

Laparoscopic vs open approach to resection of hepatocellular carcinoma in patients with known cirrhosis: Systematic review and meta-analysis

AIM: To review the currently available literature comparing laparoscopic to open resection of hepatocellular carcinoma (HCC) in patients with known liver cirrhosis.

METHODS: A literature search of MEDLINE, EMBASE, and Cochrane databases was conducted. The search terms used included (laparoscopic OR laparoscopy) AND (hepatic or liver) AND (surgery or resection) AND “hepatocellular carcinoma” AND (cirrhosis or cirrhotic). Furthermore, to widen the search, we also used the “related articles” section. Studies reporting a comparison of outcomes and methods of open vs laparoscopic hepatic resection for HCC in patients with liver cirrhosis were included. Meta-analysis of results was performed using a random effects model to compute relative risk (RR) and for dichotomous variables and standard mean differences (SMD) for continuous variables.

RESULTS: A total of 420 patients from 4 cohort studies were included in final analysis. Patients undergoing laparoscopic procedures had statistically less blood loss compared to the open cohort, SMD of -1.01 (95%CI: -1.23-0.79), P < 0.001, with a reduced risk of transfusion, RR = 0.19 (95%CI: 0.09-0.38), P < 0.001. A wider clearance at tumour resection margins was achieved following a laparoscopic approach, SMD of 0.34 (95%CI: 0.08-0.60), P = 0.011. No significant difference was noted between laparoscopic and open resection operative times, SMD of -0.15 (95%CI: 0.35-0.05), P = 0.142. The overall RR of suffering from postoperative morbidity is 0.25 in favour of the open surgery cohort (95%CI: 0.17-0.37), P < 0.001. Patients under-going laparoscopic surgery had significantly shorter length of stays in hospital compared to the open cohort, SMD of -0.53 (95%CI: -0.73 to -0.32), P < 0.001.

CONCLUSION: This review suggests that laparoscopic resection of hepatocellular carcinoma in patients with cirrhosis is safe and may provide improved patient outcomes when compared to the open technique.

Recent advances in liver resection for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy. The association of HCC with chronic liver disease (CLD) is well known and making treatment complex and challenging. The treatment of HCC must take into consideration, the severity of CLD, the stage of HCC, and the clinical condition of the patient. Liver resection (LR) is one of the most efficient treatments for patients with HCC. Better liver function assessment, increased understanding of segmental liver anatomy using more accurate imaging studies, and surgical technical progress are the important factors that have led to reduced mortality, with an expected 5 year survival of 38–61% depending on the stage of the disease. However, the procedure is applicable to <30% of all HCC patients, and 80% of the patients after LR recurred within 5 years. There are recent advances and prospects in LR for HCC in several aspects. Three-dimensional computed tomography imaging assisted preoperative surgical planning facilitates unconventional types of LR. Emerging evidences of laparoscopic hepatectomy and prospects for the use of newly developing chemotherapies as a combined therapy may lead to expanding indication of LR. LR and liver transplantation could be associated rather than considered separately with the current concepts of “bridging LR” and “salvage transplantation.”

Laparoscopic liver resections for hepatocellular carcinoma: Current role and limitations

Liver resection for hepatocellular carcinoma (HCC) is currently known to be a safer procedure than it was before because of technical advances and improvement in postoperative patient management and remains the first-line treatment for HCC in compensated cirrhosis. The aim of this review is to assess current indications, advantages and limits of laparoscopic surgery for HCC resections. We also discussed the possible evolution of this surgical approach in parallel with new technologies.

Laparoscopic liver resection: a review

Laparoscopic liver surgery was slower to develop than other fields of laparoscopic surgery because of a steep learning curve, and fear of uncontrolled bleeding or gas embolism. However, laparoscopic liver resection (LLR) is associated with significant advantages: faster recovery, less post-operative pain, less morbidity, easier subsequent surgery and better cosmetic results. Since the inception of this technique, more than 3000 procedures have been reported. The aim of this update was to review the literature in order to define the indications (malignant tumors, benign tumors, major resections), the advantages and limits of this approach as well as the expected value of new technology, such as intra-operative guidance or robotics, in the development of this branch of surgery.

Long-term outcome of laparoscopic versus open liver resection for hepatocellular carcinoma: a case-controlled study with propensity score matching

BACKGROUND

Laparoscopic liver resection (LR) for hepatocellular carcinoma (HCC) is usually applied to superficial and left-side small lesions. Therefore, well designed comparative studies about the results of LR versus open liver resection (OR) for HCC are difficult and still uncommon. The aim of this study was to compare the perioperative and long-term oncologic outcomes of LR versus OR for HCC between well-matched patient groups.

METHODS

Between January 2000 and March 2012, 205 patients (43 with intent-to-treat with LR, 162 OR) underwent primary liver resection of less than three segments for HCC in our center. To select a comparison group, propensity score matching (PSM) was used at 1:1 ratio with covariates of baseline characteristics, including tumor characteristics. Outcomes were compared between the matched groups.

RESULTS

The two groups were well balanced by PSM and 29 patients were matched respectively. In LR, there was more non-anatomical resection (65.5 vs. 34.5 %; p = 0.012), less postoperative ascites (0.0 vs. 17.2 %; p = 0.025), and shorter hospital stay (7.69 ± 2.94 vs. 13.38 ± 7.37 days; p < 0.001). With the exception of these, there were no significant differences in perioperative and long-term outcomes. The 1-, 3- and 5-year survivals were 100, 100 and 92.2 % in LR, and 96.5, 92.2 and 87.7 % in OR (p = 0.267), respectively. The 1-, 3- and 5-year disease-free survivals were 81.7, 61.7 and 54.0 % in LR, and 78.6, 60.9 and 40.1 % in OR, respectively (p = 0.929).

CONCLUSIONS

The outcome of LR for HCC was technically feasible and safe in selected patients, and LR showed similar perioperative and long-term oncologic outcomes when compared with OR matched with PSM.

[Laparoscopic liver resection: lessons learned after 132 resections]

INTRODUCTION

After 20 years of experience in laparoscopic liver surgery there is still no clear definition of the best approach (totally laparoscopic [TLS] or hand-assisted [HAS]), the indications for surgery, position, instrumentation, immediate and long-term postoperative results, etc.

AIM

To report our experience in laparoscopic liver resections (LLRs).

PATIENTS AND METHOD

Over a period of 10 years we performed 132 LLRs in 129 patients: 112 malignant tumours (90 hepatic metastases; 22 primary malignant tumours) and 20 benign lesions (18 benign tumours; 2 hydatid cysts). Twenty-eight cases received TLS and 104 had HAS.

SURGICAL TECHNIQUE

6 right hepatectomies (2 as the second stage of a two-stage liver resection); 6 left hepatectomies; 9 resections of 3 segments; 42 resections of 2 segments; 64 resections of one segment; and 5 cases of local resections.

RESULTS

There was no perioperative mortality, and morbidity was 3%. With TLS the resection was completed in 23/28 cases, whereas with HAS it was completed in all 104 cases. Transfusion: 4,5%; operating time: 150min; and mean length of stay: 3,5 days. The 1-, 3- and 5-year survival rates for the primary malignant tumours were 100, 86 and 62%, and for colorectal metastases 92, 82 and 52%, respectively.

CONCLUSION

LLR via both TLS and HAS in selected cases are similar to the results of open surgery (similar 5-year morbidity, mortality and survival rates) but with the advantages of minimally invasive surgery.

[Results after laparoscopic liver resection: an appropriate option in malignant disease]

INTRODUCTION

The laparoscopic approach is not yet widely used in liver surgery, but has proven to be safe and feasible in selected patients even in malignant disease. The experience and results of a hepato-pancreato-biliary (HPB) surgery unit in the treatment of malignant liver disease by laparoscopic approach is presented.

MATERIAL AND METHODS

Between February 2002 and May 2011, 71 laparoscopic liver resections were performed, 43 for malignant disease (only patients with more than one year of follow-up were included). Mean age was 63 years old and 58% of the patients were male. Forty-nine per cent of the lesions were located in segments ii-iii. Thirty segmentectomies were performed, 7 limited resections and 6 major hepatectomies.

RESULTS

The median operative time was 163 min. There were 3 conversions. Five cases (11%) required blood transfusion. The oral intake began at 32 h and the median hospital stay was 6.7 days. There were no reoperations and there was one case of mortality. Nine patients (21%) had postoperative complications. The mean number of resected lesions was 1.2, with an average size of 3.5 cm. All resections were R0. The median survival after resection of colorectal liver metastases (CLM) was 69% and 43.5% at 36 and 60 months, respectively, and 89% and 68% at 36 and 60 months, respectively, in hepatocellular carcinoma (HCC).

CONCLUSION

The laparoscopic liver resection in malignant disease is feasible and safe in selected patients. The same oncological rules as for open surgery should be followed. In selected patients it offers similar long-term oncological results as open surgery.

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

AIM: To conduct a meta-analysis to determine the safety and efficacy of laparoscopic liver resection (LLR) and open liver resection (OLR) for hepatocellular carcinoma (HCC).

METHODS: PubMed (Medline), EMBASE and Science Citation Index Expanded and Cochrane Central Register of Controlled Trials in the Cochrane Library were searched systematically to identify relevant comparative studies reporting outcomes for both LLR and OLR for HCC between January 1992 and February 2012. Two authors independently assessed the trials for inclusion and extracted the data. Meta-analysis was performed using Review Manager Version 5.0 software (The Cochrane Collaboration, Oxford, United Kingdom). Pooled odds ratios (OR) or weighted mean differences (WMD) with 95%CI were calculated using either fixed effects (Mantel-Haenszel method) or random effects models (DerSimonian and Laird method). Evaluated endpoints were operative outcomes (operation time, intraoperative blood loss, blood transfusion requirement), postoperative outcomes (liver failure, cirrhotic decompensation/ascites, bile leakage, postoperative bleeding, pulmonary complications, intraabdominal abscess, mortality, hospital stay and oncologic outcomes (positive resection margins and tumor recurrence).

RESULTS: Fifteen eligible non-randomized studies were identified, out of which, 9 high-quality studies involving 550 patients were included, with 234 patients in the LLR group and 316 patients in the OLR group. LLR was associated with significantly lower intraoperative blood loss, based on six studies with 333 patients [WMD: -129.48 mL; 95%CI: -224.76-(-34.21) mL; P = 0.008]. Seven studies involving 416 patients were included to assess blood transfusion requirement between the two groups. The LLR group had lower blood transfusion requirement (OR: 0.49; 95%CI: 0.26-0.91; P = 0.02). While analyzing hospital stay, six studies with 333 patients were included. Patients in the LLR group were found to have shorter hospital stay [WMD: -3.19 d; 95%CI: -4.09-(-2.28) d; P < 0.00001] than their OLR counterpart. Seven studies including 416 patients were pooled together to estimate the odds of developing postoperative ascites in the patient groups. The LLR group appeared to have a lower incidence of postoperative ascites (OR: 0.32; 95%CI: 0.16-0.61; P = 0.0006) as compared with OLR patients. Similarly, fewer patients had liver failure in the LLR group than in the OLR group (OR: 0.15; 95%CI: 0.02-0.95; P = 0.04). However, no significant differences were found between the two approaches with regards to operation time [WMD: 4.69 min; 95%CI: -22.62-32 min; P = 0.74], bile leakage (OR: 0.55; 95%CI: 0.10-3.12; P = 0.50), postoperative bleeding (OR: 0.54; 95%CI: 0.20-1.45; P = 0.22), pulmonary complications (OR: 0.43; 95%CI: 0.18-1.04; P = 0.06), intra-abdominal abscesses (OR: 0.21; 95%CI: 0.01-4.53; P = 0.32), mortality (OR: 0.46; 95%CI: 0.14-1.51; P = 0.20), presence of positive resection margins (OR: 0.59; 95%CI: 0.21-1.62; P = 0.31) and tumor recurrence (OR: 0.95; 95%CI: 0.62-1.46; P = 0.81).

CONCLUSION: LLR appears to be a safe and feasible option for resection of HCC in selected patients based on current evidence. However, further appropriately designed randomized controlled trials should be undertaken to ascertain these findings.

Treatment of hepatocellular carcinoma: a systematic review

Hepatocellular carcinoma (HCC) is one of the most common malignancies, with an increasing incidence. With advances in surgical techniques and instrumentation and the development of molecular-target drugs, a number of potentially curative treatments have become available. Management of HCC patients depends on the stage of their tumor. Liver resection remains the first choice for very early-stage HCC, but it is being challenged by local ablative therapy. For early-stage HCC that meet the Milan criteria, liver transplantation still offers a better outcome; however, local ablative therapy can be a substitute when transplantation is not feasible. Local ablation is also used as a bridging therapy toward liver transplantation. HCC recurrence is the main obstacle to successful treatment, and there is currently no effective means of preventing or treating HCC recurrence. Transarterial therapy is considered suitable for intermediate-stage HCC, while sorafenib is recommended for advanced-stage HCC. This stage-based approach to therapy not only provides acceptable outcomes but also improves the quality of life of HCC patients. Because of the complexity of HCC, therapeutic approaches must be adapted according to the characteristics of each individual patient. This review discusses the current standards and trends in the treatment of HCC.

Blood Loss and Massive Transfusion in Patients Undergoing Major Oncological Surgery: What Do We Know?

Patients with solid malignancies who were not candidates for tumor resections in the past are now presenting for extensive oncological resections. Cancer patients are at risk for thromboembolic complications due to an underlying hypercoagulable state; however, some patients may have an increased risk for bleeding due to the effects of chemotherapy, the administration of anticoagulant drugs, tumor-related fibrinolysis, tumor location, tumor vascularity, and extent of disease. A common potential complication of all complex oncological surgeries is massive intra- and postoperative hemorrhage and the subsequent risk for massive blood transfusion. This can be anticipated or unexpected. Several surgical and anesthesia interventions including preoperative tumor embolization, major vessel occlusion, hemodynamic manipulation, and perioperative antifibrinolytic therapy have been used to prevent or control blood loss with varying success. The exact incidence of massive blood transfusion in oncological surgery is largely unknown and/or underreported. The current literature mostly consists of purely descriptive observational studies. Thus, recommendation regarding specific perioperative intervention cannot be made at this point, and more research is warranted.