Trends in the characteristics and perioperative outcomes of patients undergoing laparoscopic and open resections for benign liver lesions: An international multicenter retrospective cohort study of 845 patients

BACKGROUND

Solid benign liver lesions (BLL) are increasingly discovered, but clear indications for surgical treatment are often lacking. Concomitantly, laparoscopic liver surgery is increasingly performed. The aim of this study was to assess if the availability of laparoscopic surgery has had an impact on the characteristics and perioperative outcomes of patients with BLL.

METHODS

This is a retrospective international multicenter cohort study, including patients undergoing a laparoscopic or open liver resection for BLL from 19 centers in eight countries. Patients were divided according to the time period in which they underwent surgery (2008-2013, 2014-2016, and 2017-2019). Unadjusted and risk-adjusted (using logistic regression) time-trend analyses were performed. The primary outcome was textbook outcome (TOLS), defined as the absence of intraoperative incidents ≥ grade 2, bile leak ≥ grade B, severe complications, readmission and 90-day or in-hospital mortality, with the absence of a prolonged length of stay added to define TOLS+.

RESULTS

In the complete dataset comprised of patients that underwent liver surgery for all indications, the proportion of patients undergoing liver surgery for benign disease remained stable (12.6% in the first time period, 11.9% in the second time period and 12.1% in the last time period, p = 0.454). Overall, 845 patients undergoing a liver resection for BLL in the first (n = 374), second (n = 258) or third time period (n = 213) were included. The rates of ASA-scores≥3 (9.9%-16%,p < 0.001), laparoscopic surgery (57.8%-77%,p < 0.001), and Pringle maneuver use (33.2%-47.2%,p = 0.001) increased, whereas the length of stay decreased (5 to 4 days,p < 0.001). There were no significant changes in the TOLS rate (86.6%-81.3%,p = 0.151), while the TOLS + rate increased from 41.7% to 58.7% (p < 0.001). The latter result was confirmed in the risk-adjusted analyses (aOR 1.849,p = 0.004).

CONCLUSION

The surgical treatment of BLL has evolved with an increased implementation of the laparoscopic approach and a decreased length of stay. This evolution was paralleled by stable TOLS rates above 80% and an increase in the TOLS + rate.

Risk Factors and Outcomes of Open Conversion During Minimally Invasive Major Hepatectomies: An International Multicenter Study on 3880 Procedures Comparing the Laparoscopic and Robotic Approaches

INTRODUCTION

Despite the advances in minimally invasive (MI) liver surgery, most major hepatectomies (MHs) continue to be performed by open surgery. This study aimed to evaluate the risk factors and outcomes of open conversion during MI MH, including the impact of the type of approach (laparoscopic vs. robotic) on the occurrence and outcomes of conversions.

METHODS

Data on 3880 MI conventional and technical (right anterior and posterior sectionectomies) MHs were retrospectively collected. Risk factors and perioperative outcomes of open conversion were analyzed. Multivariate analysis, propensity score matching, and inverse probability treatment weighting analysis were performed to control for confounding factors.

RESULTS

Overall, 3211 laparoscopic MHs (LMHs) and 669 robotic MHs (RMHs) were included, of which 399 (10.28%) had an open conversion. Multivariate analyses demonstrated that male sex, laparoscopic approach, cirrhosis, previous abdominal surgery, concomitant other surgery, American Society of Anesthesiologists (ASA) score 3/4, larger tumor size, conventional MH, and Institut Mutualiste Montsouris classification III procedures were associated with an increased risk of conversion. After matching, patients requiring open conversion had poorer outcomes compared with non-converted cases, as evidenced by the increased operation time, blood transfusion rate, blood loss, hospital stay, postoperative morbidity/major morbidity and 30/90-day mortality. Although RMH showed a decreased risk of conversion compared with LMH, converted RMH showed increased blood loss, blood transfusion rate, postoperative major morbidity and 30/90-day mortality compared with converted LMH.

CONCLUSIONS

Multiple risk factors are associated with conversion. Converted cases, especially those due to intraoperative bleeding, have unfavorable outcomes. Robotic assistance seemed to increase the feasibility of the MI approach, but converted robotic procedures showed inferior outcomes compared with converted laparoscopic procedures.

Robotic pancreas surgery: an overview of history and update on technique, outcomes, and financials

The use robotics in surgery is gaining momentum. This approach holds substantial promise in pancreas surgery. Robotic surgery for pancreatic lesions and malignancies has become well accepted and is expanding to more and more center annually. The number of centers using robotics in pancreatic surgery is rapidly increasing. The most studied robotic pancreas surgeries are pancreaticoduodenectomy and distal pancreatectomy. Most studies are in their early phases, but they report that robotic pancreas surgery is safe feasible. Robotic pancreas surgery offers several advantages over open and laparoscopic techniques. Data regarding costs of robotics versus conventional techniques is still lacking. Robotic pancreas surgery is still in its early stages. It holds promise to become the new surgical standard for pancreatic resections in the future, however, more research is still needed to establish its safety, cost effectiveness and efficacy in providing the best outcomes.

Comparing practice and outcome of laparoscopic liver resection between high-volume expert centres and nationwide low-to-medium volume centres

BACKGROUND

Based on excellent outcomes from high-volume centres, laparoscopic liver resection is increasingly being adopted into nationwide practice which typically includes low-medium volume centres. It is unknown how the use and outcome of laparoscopic liver resection compare between high-volume centres and low-medium volume centres. This study aimed to compare use and outcome of laparoscopic liver resection in three leading European high-volume centres and nationwide practice in the Netherlands.

METHOD

An international, retrospective multicentre cohort study including data from three European high-volume centres (Oslo, Southampton and Milan) and all 20 centres in the Netherlands performing laparoscopic liver resection (low-medium volume practice) from January 2011 to December 2016. A high-volume centre is defined as a centre performing >50 laparoscopic liver resections per year. Patients were retrospectively stratified into low, moderate- and high-risk Southampton difficulty score groups.

RESULTS

A total of 2425 patients were included (1540 high-volume; 885 low-medium volume). The median annual proportion of laparoscopic liver resection was 42.9 per cent in high-volume centres and 7.2 per cent in low-medium volume centres. Patients in the high-volume centres had a lower conversion rate (7.4 versus 13.1 per cent; P < 0.001) with less intraoperative incidents (9.3 versus 14.6 per cent; P = 0.002) as compared to low-medium volume centres. Whereas postoperative morbidity and mortality rates were similar in the two groups, a lower reintervention rate (5.1 versus 7.2 per cent; P = 0.034) and a shorter postoperative hospital stay (3 versus 5 days; P < 0.001) were observed in the high-volume centres as compared to the low-medium volume centres. In each Southampton difficulty score group, the conversion rate was lower and hospital stay shorter in high-volume centres. The rate of intraoperative incidents did not differ in the low-risk group, whilst in the moderate-risk and high-risk groups this rate was lower in high-volume centres (absolute difference 6.7 and 14.2 per cent; all P < 0.004).

CONCLUSION

High-volume expert centres had a sixfold higher use of laparoscopic liver resection, less conversions, and shorter hospital stay, as compared to a nationwide low-medium volume practice. Stratification into Southampton difficulty score risk groups identified some differences but largely outcomes appeared better for high-volume centres in each risk group.

The impact of enhanced recovery on open and laparoscopic liver resections

Enhanced recovery after surgery programs (ERP) have been implemented in many surgical specialties. Their impact in liver surgery is poorly understood and approach-specific ERPs have not yet been assessed. This retrospective study aims to analyse the effect of such programs on liver resection. All patients undergoing liver resection at a tertiary referral centre between January 2009 and April 2019 were identified. Primary outcome was the length of stay (LOS), secondary outcomes were functional recovery, complications and readmission rates. Patients in the ERP with different protocols for open, laparoscopic, major and minor resections were compared to a historical cohort. Of 1056 patients, 644 were treated within the ERP. A comparable duration of hospital stay [7 days (IQR (interquartile range) 6-12) vs 7 days (IQR 5-9) p = 0.047] and faster functional recovery with fewer complications was found in the ERP group [94 (50.5%) vs 103 (35.9%) p < 0.002]. Those advantages were smaller after open minor compared to open major resection. In patients undergoing laparoscopic resection no differences were observed except for a lower readmission rate [21 (9.3%) vs 13 (3.6%) p = 0.005]. Multivariable analysis showed that laparoscopy was associated with a shorter LOS. ERPs offer significant advantages in open liver surgery. Those advantages are less evident after laparoscopic resection.

Surgical technique and clinical results of one- or two-stage laparoscopic right hemihepatectomy after portal vein embolization in patients with initially unresectable colorectal liver metastases: A case series

BACKGROUND

The use of the laparoscopic approach in one-stage or second-step of two-stage right hemihepatectomy (RHH) after portal vein embolization (PVE) in patients with initially unresectable colorectal liver metastases (CRLMs) is technically demanding. Currently, there is limited published data regarding the technique and results required to better understand its safety and feasibility. This paper reports our experience, results, techniques and variety of tips and tricks (highlighted in the attached video), to facilitate this resection.

METHODS

A prospectively maintained database of laparoscopic liver surgery within our unit at a tertiary referral centre between August 2003 and March 2019 was reviewed. Patients with initially unresectable CRLMs who underwent laparoscopic RHH or extended RHH after PVE in the context of a one or two-stage procedure were included.

RESULTS

Between August 2003 and March 2019, 19 patients with initially unresectable CRLMs underwent laparoscopic RHH after PVE. Twelve patients (63.2%) had RHH in the context of a two-stage hepatectomy and 7 as a one-stage procedure. Median time interval between PVE and surgery was 42.5 days (IQR, 34.5-60.0 days). Mean operating time was 351.8 ± 80.5 minutes. Median blood loss was 850 mL (IQR, 475-1350 mL). Conversion to open surgery occurred in 2 of 19 cases (10.5%). Severe postoperative morbidity occurred in 2 patients. The mortality rate was 5.3%. Median postoperative hospital stay was 5 days (IQR, 4-7 days). Radical resection was obtained in eighteen patients (94.7%).

CONCLUSION

Laparoscopic RHH after PVE in the context of a one- or two-stage resection in patients with initially unresectable CRLMs is a safe and feasible procedure with favourable oncological outcomes.

Optimal oncologic treatment of rectal cancer in patients over 75 years old: Results of a strategy based on oncogeriatric evaluation

BACKGROUND

Few data are available on the management of elderly rectal cancer patients, and especially on the ability to provide optimal oncological treatment. The aim of this study was to determine the feasibility and results of multimodality treatment for rectal cancer in patients 75years and older after simplified comprehensive geriatric assessment (CGA) according to Balducci score.

METHODS

We reviewed the charts of elderly patients who underwent surgery for localized middle or low rectal cancer. Patients were classified into three CGA groups depending on their functional reserve, comorbidities, geriatric syndromes, and life expectancy.

RESULTS

Neoadjuvant therapy was discussed for 27 patients (47%), but only 56% of them were treated, including 8, 7, and 1 patient from CGA groups 1, 2, and 3, respectively. Fifty-three patients (93%) underwent sphincter-preserving surgical resection and four patients underwent abdominoperineal resection (7%). Postoperative complications were observed in 21 patients (37%). The postoperative complication rate was correlated non-significantly with age (<85years: 40.6%; ≥85years: 57.1%; P=0.3), and with the CGA (P=0.64). In total, 10 patients (18%) had definitive colostomy, including five anastomotic leakages (9%), and one incontinence (2%). The total rate of sphincter preservation was 82% (n=47). The risk of secondary definitive colonic stoma formation was not correlated with CGA (group 1: 14%; group 2/3: 16%; P=0.8). Estimated OS at five years was 52%.

CONCLUSIONS

After routine geriatric assessment, elderly rectal cancer patients have good rates of sphincter conservation and acceptable morbidity/mortality.

Laparoscopic left liver resections: how far can we go?

INTRODUCTION

The aim of this study was to analyse the outcomes of laparoscopic anatomic hepatectomies of the left liver segments.

METHODS

This is a retrospective multicentre study including all patients operated on laparoscopically divided into unisegmentectomy of 2, 3 or 4 (Group 1), left lobectomy (or left lateral sectionectomy LLS) (Group 2), left hepatectomy (Group 3) and extended left hepatectomy (Group 4) between 2000 and 2016. These four groups were compared in terms of demographics, intraoperative data and postoperative outcomes.

RESULTS

Among the 190 selected patients, the groups 1, 2, 3, 4 included 25 (13.2%), 116 (61.0%), 27 (14.2%) and 22 (11.6%) patients, respectively. The cohorts were comparable except for the number of lesions (p = 0.001) and tumour diameter (p = 0.004). The operative time, blood loss and the use of vascular clamping were more frequent in the Groups 3 and 4 (p = 0.0001), as is the rate of conversion to laparotomy (p = 0.001). Total morbidity was 23.3%, and major complications were more frequent in Group 4 (p = 0.0001). The prevalence of hepatic complications (11.6%), intra-abdominal collections (7.4%) and respiratory complications (3.7%) was proportionally correlated to the hepatectomy extension (p = 0.0001).

CONCLUSION

All laparoscopic left liver resections seem safe and feasible even though extended hepatectomy is associated with a significant morbidity.