Evolution of laparoscopic liver surgery: 20-year experience of a Norwegian high-volume referral center

BACKGROUND

Laparoscopic liver surgery has evolved to become a standard surgical approach in many specialized centers worldwide. In this study we present the evolution of laparoscopic liver surgery at a single high-volume referral center since its introduction in 1998.

METHODS

Patients who underwent laparoscopic liver resection (LLR) between August 1998 and December 2018 at the Oslo University Hospital were analyzed. Perioperative outcomes were compared between three time periods: early (1998 to 2004), middle (2005 to 2012) and recent (2013-2018).

RESULTS

Up to December 2020, 1533 LLRs have been performed. A total of 1232 procedures were examined (early period, n = 62; middle period, n = 367 and recent period, n = 803). Colorectal liver metastasis was the main indication for surgery (68%). The rates of conversion to laparotomy and hand-assisted laparoscopy were 3.2% and 1.4%. The median operative time and blood loss were 130 min [interquartile range (IQR), 85-190] and 220 ml (IQR, 50-600), respectively. The total postoperative complications rate was 20.3% and the 30-day mortality was 0.3%. The median postoperative stay was two (IQR, 2-4) days. When comparing perioperative outcomes between the three time periods, shorter operation time (median, from 182 to 120 min, p < 0.001), less blood loss (median, from 550 to 200 ml, p = 0.023), decreased rate of conversions to laparotomy (from 8 to 3%) and shorter postoperative hospital stay (median, from 3 to 2 days, p < 0.001) was observed in the later periods, while the number of more complex liver resections had increased.

CONCLUSION

During the last two decades, the indications, the number of patients and the complexity of laparoscopic liver procedures have expanded significantly. Initially being an experimental approach, laparoscopic liver surgery is now safely implemented across our unit and has become the method of choice for surgical treatment of most liver tumors.

Impact of resection margins for colorectal liver metastases in laparoscopic and open liver resection: a propensity score analysis

BACKGROUND

There is no clear consensus over the optimal width of resection margin for colorectal liver metastases (CRLM), with evolving definitions alongside the advances on the management of the disease. In addition, data on the impact of resection margin after laparoscopic liver resection are still scarce.

METHODS

Prospectively maintained databases of patients undergoing open or laparoscopic CRLM resection in 7 European tertiary hepatobiliary referral centres were reviewed. After propensity score matching (PSM), the influence of 1 mm and wider margins on OS and DFS were evaluated in open and laparoscopic cohorts.

RESULTS

After PSM, 648 patients were comparable in each group. The incidence of positive margins (< 1 mm) was similar in open and laparoscopic groups (17% vs 13%, p = 0,142). Margins < 1 mm were associated with shorter RFS in open (12 vs 26 months, p = 0.042) and in laparoscopic group (13 vs 23, p = 0,002). Margins < 1 mm were associated with shorter OS in open (36 vs 57 months, p = 0.027), but not in laparoscopic group (49 vs 60, p = 0,177). Subgroups with margins ≥ 1 mm (1-4 mm, 5-9 mm, ≥ 10 mm) presented similar RFS in open (p = 0,251) or laparoscopic cohorts (p = 0.117), as well as similar OS in open (p = 0.295) or laparoscopic cohorts (p = 0.908). In the presence of liver recurrence, repeat liver resection was performed in 70 (30%) patients in the open group and 88 (48%) in the laparoscopic group (p < 0.001).

CONCLUSIONS

Our study suggests that a positive resection margin (less than 1 mm) width does not impact OS after laparoscopic resection of CRLMs as it does in open liver resection. However, a positive margin continues to affect RFS in open and laparoscopic resection. Wider margins than 1 mm do not seem to improve oncological results in open or laparoscopic surgery.

Pure laparoscopic versus open hemihepatectomy: a critical assessment and realistic expectations - a propensity score-based analysis of right and left hemihepatectomies from nine European tertiary referral centers

INTRODUCTION

A stronger evidence level is needed to confirm the benefits and limits of laparoscopic hemihepatectomies.

METHODS

Laparoscopic and open hemihepatectomies from nine European referral centers were compared after propensity score matching (right and left hemihepatectomies separately, and benign and malignant diseases sub-analyses).

RESULTS

Five hundred and forty-five laparoscopic hemihepatectomies were compared with 545 open. Laparoscopy was associated with reduced blood loss (P < 0.001), postoperative stay (P < 0.001) and minor morbidity (P = 0.002), supported by a lower Comprehensive Complication Index (CCI) (P = 0.035). Laparoscopic right hemihepatectomies were associated with lower ascites (P = 0.016), bile leak (P = 0.001) and wound infections (P = 0.009). Laparoscopic left hemihepatectomies exhibited a lower incidence of bile leak and cardiovascular complications (P = 0.024; P = 0.041), lower minor and major morbidity (P = 0.003; P = 0.044) and reduced CCI (P = 0.002). Laparoscopic major hepatectomies (LMH) for benign disease were associated with lower blood loss (P = 0.001) and bile leaks (P = 0.037) and shorter total stay (P < 0.001). LMH for malignancy were associated with lower blood loss (P < 0.001) and minor morbidity (P = 0.027) supported by a lower CCI (P = 0.021) and shorter stay (P < 0.001).

CONCLUSION

This multicenter study confirms some associated advantages of laparoscopic left and right hemihepatectomies in malignant and benign conditions highlighting the need for realistic expectations of the minimally invasive approach based on the resected hemiliver and the patients treated.

Quality of life from a randomized trial of laparoscopic or open liver resection for colorectal liver metastases

Background

Most treatments for cancer cause a decline in patients' health-related quality of life (HRQoL). Limiting this decline is a universal goal for healthcare providers. Using minimally invasive instead of open surgical techniques might be one way to achieve this. The aim of this study was to compare postoperative HRQoL after open and laparoscopic liver resection.

Methods

This was a predefined substudy of an RCT comparing open with laparoscopic liver resection. Patients with colorectal liver metastases were assigned randomly to open or laparoscopic parenchyma-sparing liver resection. HRQoL was assessed with the Short Form 36 questionnaire at baseline, and 1 and 4 months after surgery.

Results

A total of 280 patients were randomized, of whom 273 underwent surgery (129 laparoscopic, 144 open); 682 questionnaires (83.3 per cent) were available for analysis. One month after surgery, patients in the laparoscopic surgery group reported reduced scores in two HRQoL domains (physical functioning and role physical), whereas those in the open surgery group reported reduced scores in five domains (physical functioning, role physical, bodily pain, vitality and social functioning). Four months after surgery, HRQoL scores in the laparoscopic group had returned to preoperative levels, whereas patients in the open group reported reduced scores for two domains (role physical and general health). The between-group difference was statistically significant in favour of laparoscopy for four domains after 1 month (role physical, bodily pain, vitality and social functioning) and for one domain after 4 months (role physical).

Conclusion

Patients assigned to laparoscopic liver surgery reported better postoperative HRQoL than those assigned to open liver surgery. For role limitations caused by physical health problems, patients in the laparoscopic group reported better scores up to 4 months after surgery. Registration number: NCT01516710 (http://www.clinicaltrials.gov).

Can we ablate liver lesions close to large portal and hepatic veins with MR-guided HIFU? An experimental study in a porcine model

OBJECTIVES

Invasive treatment of tumors adjacent to large hepatic vessels is a continuous clinical challenge. The primary aim of this study was to examine the feasibility of ablating liver tissue adjacent to large hepatic and portal veins with magnetic resonance imaging-guided high-intensity focused ultrasound (MRgHIFU). The secondary aim was to compare sonication data for ablations performed adjacent to hepatic veins (HV) versus portal veins (PV).

MATERIALS AND METHODS

MRgHIFU ablations were performed in six male land swine under general anesthesia. Ablation cells of either 4 or 8 mm diameter were planned in clusters (two/animal) adjacent either to HV (n = 6) or to PV (n = 6), with diameter ≥ 5 mm. Ablations were made using 200 W and 1.2 MHz. Post-procedure evaluation was made on contrast-enhanced MRI (T1w CE-MRI), histopathology, and ablation data from the HIFU system.

RESULTS

A total of 153 ablations in 81 cells and 12 clusters were performed. There were visible lesions with non-perfused volumes in all animals on T1w CE-MRI images. Histopathology showed hemorrhage and necrosis in all 12 clusters, with a median shortest distance to vessel wall of 0.4 mm (range 0-2.7 mm). Edema and endothelial swelling were observed without vessel wall rupture. In 8-mm ablations (n = 125), heat sink was detected more often for HV (43%) than for PV (19%; p = 0.04).

CONCLUSIONS

Ablations yielding coagulative necrosis of liver tissue can be performed adjacent to large hepatic vessels while keeping the vessel walls intact. This indicates that perivascular tumor ablation in the liver is feasible using MRgHIFU.

KEY POINTS

• High-intensity focused ultrasound ablation is a non-invasive treatment modality that can be used for treatment of liver tumors. • This study shows that ablations of liver tissue can be performed adjacent to large hepatic vessels in an experimental setting. • Liver tumors close to large vessels can potentially be treated using this modality.

Multicentre propensity score-matched study of laparoscopic versus open repeat liver resection for colorectal liver metastases

BACKGROUND

Repeat liver resection is often the best treatment option for patients with recurrent colorectal liver metastases (CRLM). Repeat resections can be complex, however, owing to adhesions and altered liver anatomy. It remains uncertain whether the advantages of a laparoscopic approach are upheld in this setting. The aim of this retrospective, propensity score-matched study was to compare the short-term outcome of laparoscopic (LRLR) and open (ORLR) repeat liver resection.

METHODS

A multicentre retrospective propensity score-matched study was performed including all patients who underwent LRLRs and ORLRs for CRLM performed in nine high-volume centres from seven European countries between 2000 and 2016. Patients were matched based on propensity scores in a 1 : 1 ratio. Propensity scores were calculated based on 12 preoperative variables, including the approach to, and extent of, the previous liver resection. Operative outcomes were compared using paired tests.

RESULTS

Overall, 425 repeat liver resections were included. Of 271 LRLRs, 105 were matched with an ORLR. Baseline characteristics were comparable after matching. LRLR was associated with a shorter duration of operation (median 200 (i.q.r. 123-273) versus 256 (199-320) min; P < 0·001), less intraoperative blood loss (200 (50-450) versus 300 (100-600) ml; P = 0·077) and a shorter postoperative hospital stay (5 (3-8) versus 6 (5-8) days; P = 0·028). Postoperative morbidity and mortality rates were similar after LRLR and ORLR.

CONCLUSION

LRLR for CRLM is feasible in selected patients and may offer advantages over an open approach.

The Southampton Consensus Guidelines for Laparoscopic Liver Surgery: From Indication to Implementation

OBJECTIVE

The European Guidelines Meeting on Laparoscopic Liver Surgery was held in Southampton on February 10 and 11, 2017 with the aim of presenting and validating clinical practice guidelines for laparoscopic liver surgery.

BACKGROUND

The exponential growth of laparoscopic liver surgery in recent years mandates the development of clinical practice guidelines to direct the speciality's continued safe progression and dissemination.

METHODS

A unique approach to the development of clinical guidelines was adopted. Three well-validated methods were integrated: the Scottish Intercollegiate Guidelines Network methodology for the assessment of evidence and development of guideline statements; the Delphi method of establishing expert consensus, and the AGREE II-GRS Instrument for the assessment of the methodological quality and external validation of the final statements.

RESULTS

Along with the committee chairman, 22 European experts; 7 junior experts and an independent validation committee of 11 international surgeons produced 67 guideline statements for the safe progression and dissemination of laparoscopic liver surgery. Each of the statements reached at least a 95% consensus among the experts and were endorsed by the independent validation committee.

CONCLUSION

The European Guidelines Meeting for Laparoscopic Liver Surgery has produced a set of clinical practice guidelines that have been independently validated for the safe development and progression of laparoscopic liver surgery. The Southampton Guidelines have amalgamated the available evidence and a wealth of experts' knowledge taking in consideration the relevant stakeholders' opinions and complying with the international methodology standards.

Development and validation of a difficulty score to predict intraoperative complications during laparoscopic liver resection

Background

Previous studies have demonstrated that patient, surgical, tumour and operative variables affect the complexity of laparoscopic liver resections. However, current difficulty scoring systems address only tumour factors. The aim of this study was to develop and validate a predictive model for the risk of intraoperative complications during laparoscopic liver resections.

Methods

The prospectively maintained databases of seven European tertiary referral liver centres were compiled. Data from two-thirds of the patients were used for development and one-third for validation of the model. Intraoperative complications were based on a modified Satava classification. Using the methodology of the Framingham Heart Study, developed to identify risk factors that contribute to the development of cardiovascular disease, factors found to predict intraoperative complications independently were assigned points, and grouped into low-, moderate-, high- and extremely high-risk groups based on the likelihood of intraoperative complications.

Results

A total of 2856 patients were included. Neoadjuvant chemotherapy, lesion type and size, classification of resection and previous open liver resection were found to be independent predictors of intraoperative complications. Patients with intraoperative complications had a longer duration of hospital stay (5 versus 4 days; P &lt; 0·001), higher complication rates (32·5 versus 15·5 per cent; P &lt; 0·001), and higher 30-day (3·0 versus 0·3 per cent; P &lt; 0·001) and 90-day (3·8 versus 0·8 per cent; P &lt; 0·001) mortality rates than those who did not. The model was able to predict intraoperative complications (area under the receiver operating characteristic (ROC) curve (AUC) 0·677, 95 per cent c.i. 0·647 to 0·706) as well as postoperative 90-day mortality (AUC 0·769, 0·681 to 0·858).

Conclusion

This comprehensive scoring system, based on patient, surgical and tumour factors, and developed and validated using a large multicentre European database, helped estimate the risk of intraoperative complications.

Superior mesenteric artery syndrome: quality of life after laparoscopic duodenojejunostomy

In this study, we present results after laparoscopic duodenojejunostomy for five patients with protracted superior mesenteric artery syndrome. The procedure can be performed with minimal perioperative risk and very short postoperative stay. It provides significant postoperative symptom relief for many patients with typical presentation of the syndrome.

Laparoscopic Parenchyma-sparing Liver Resection for Colorectal Metastases

Background

Laparoscopic liver resection (LLR) of colorectal liver metastases (CLM) is increasingly performed in specialized centers. While there is a trend towards a parenchyma-sparing strategy in multimodal treatment for CLM, its role is yet unclear. In this study we present short- and long-term outcomes of laparoscopic parenchyma-sparing liver resection (LPSLR) at a single center.

Patients and methods

LLR were performed in 951 procedures between August 1998 and March 2017 at Oslo University Hospital, Oslo, Norway. Patients who primarily underwent LPSLR for CLM were included in the study. LPSLR was defined as non-anatomic hence the patients who underwent hemihepatectomy and sectionectomy were excluded. Perioperative and oncologic outcomes were analyzed. The Accordion classification was used to grade postoperative complications. The median follow-up was 40 months.

Results

296 patients underwent primary LPSLR for CLM. A single specimen was resected in 204 cases, multiple resections were performed in 92 cases. 5 laparoscopic operations were converted to open. The median operative time was 134 minutes, blood loss was 200 ml and hospital stay was 3 days. There was no 90-day mortality in this study. The postoperative complication rate was 14.5%. 189 patients developed disease recurrence. Recurrence in the liver occurred in 146 patients (49%), of whom 85 patients underwent repeated surgical treatment (liver resection [n = 69], ablation [n = 14] and liver transplantation [n = 2]). Five-year overall survival was 48%, median overall survival was 56 months.

Conclusions

LPSLR of CLM can be performed safely with the good surgical and oncological results. The technique facilitates repeated surgical treatment, which may improve survival for patients with CLM.

Evolution of Laparoscopic Liver Surgery from Innovation to Implementation to Mastery: Perioperative and Oncologic Outcomes of 2,238 Patients from 4 European Specialized Centers

BACKGROUND

First seen as an innovation for select patients, laparoscopic liver resection (LLR) has evolved since its introduction, resulting in worldwide use. Despite this, it is still limited mainly to referral centers. The aim of this study was to evaluate a large cohort undergoing LLR from 2000 to 2015, focusing on the technical approaches, perioperative and oncologic outcomes, and evolution of practice over time.

STUDY DESIGN

The demographics and indications, intraoperative, perioperative, and oncologic outcomes of 2,238 patients were evaluated. Trends in practice and outcomes over time were assessed.

RESULTS

The percentage of LLR performed yearly has increased from 5% in 2000 to 43% in 2015. Pure laparoscopy was used in 98.3% of cases. Wedge resections were the most common operation; they were predominant at the beginning of LLR and then decreased and remained steady at approximately 53%. Major hepatectomies were initially uncommon, then increased and reached a stable level at approximately 16%. Overall, 410 patients underwent resection in the posterosuperior segments; these were more frequent with time, and the highest percentage was in 2015 (26%). Blood loss, operative time, and conversion rate improved significantly with time. The 5-year overall survival rates were 73% and 54% for hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM), respectively. The 5-year, recurrence-free survival rates were 50% and 37% for HCC and CRLM, respectively.

CONCLUSIONS

Since laparoscopy was introduced, a long implementation process has been necessary to allow for standardization and improvement in surgical care, mastery of the technique, and the ability to obtain good perioperative results with safe oncologic outcomes.

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.

Laparoscopic Versus Open Liver Resection for Colorectal Metastases in Elderly and Octogenarian Patients: A Multicenter Propensity Score Based Analysis of Short- and Long-term Outcomes

OBJECTIVE

This study aims to compare the perioperative and oncological outcomes of laparoscopic and open liver resection for colorectal liver metastases in the elderly.

BACKGROUND

Laparoscopic liver resection has been associated with less morbidity and similar oncological outcomes to open liver resection for colorectal liver metastases (CRLMs). It has been reported that these benefits continue to be observed in elderly patients. However, in previous studies, patients over 70 or 75 years were considered as a single, homogenous population raising questions regarding the true impact of the laparoscopic approach on this diverse group of elderly patients.

METHOD

Prospectively maintained databases of all patients undergoing liver resection for CRLM in 5 tertiary liver centers were included. Those over 70-years old were selected for this study. The cohort was divided in 3 subgroups based on age. A comparative analysis was performed after the implementation of propensity score matching on the 2 main cohorts (laparoscopic and open groups) and also on the study subgroups.

RESULTS

A total of 775 patients were included in the study. After propensity score matching 225 patients were comparable in each of the main groups. Lower blood loss (250 vs 400 mL, P = 0.001), less overall morbidity (22% vs 39%, P = 0.001), shorter High Dependency Unit (2 vs. 6 days, P = 0.001), and total hospital stay (5 vs. 8 days, P = 0.001) were observed after laparoscopic liver resection. Comparable rates of R0 resection (88% vs 88%, P = 0.999), median recurrence-free survival (33 vs 27 months, P = 0.502), and overall survival (51 vs 45 months, P = 0.671) were observed. The advantages seen with the laparoscopic approach were reproduced in the 70 to 74-year old subgroup; however there was a gradual loss of these advantages with increasing age.

CONCLUSIONS

In patients over 70 years of age laparoscopic liver resection, for colorectal liver metastases, offers significant lower morbidity, and a shorter hospital stay with comparable oncological outcomes when compared with open liver resection. However, the benefits of the laparoscopic approach appear to fade with increasing age, with no statistically significant benefits in octogenarians except for a lower High Dependency Unit stay.

Outcome after laparoscopic and open resections of posterosuperior segments of the liver

BACKGROUND

Laparoscopic resection of posterosuperior (PS) segments of the liver is hindered by limited visualization and curvilinear resection planes. The aim of this study was to compare outcomes after open and laparoscopic liver resections of PS segments.

METHODS

Patients who underwent minor open liver resection (OLR) and laparoscopic liver resection (LLR) between 2006 and 2014 were identified from the institutional databases of seven tertiary referral European hepatobiliary surgical units. Propensity score-matched analysis was used to match groups for known confounders. Perioperative outcomes including complications were assessed using the Dindo-Clavien classification, and the comprehensive complication index was calculated. Survival was analysed with the Kaplan-Meier method.

RESULTS

Some 170 patients underwent OLR and 148 had LLR. After propensity score-matched analysis, 86 patients remained in both groups. Overall postoperative complication rates were significantly higher after OLR compared with LLR: 28 versus 14 per cent respectively (P = 0·039). The mean(s.d.) comprehensive complication index was higher in the OLR group, although the difference was not statistically significant (26·7(16·6) versus 18·3(8·0) in the LLR group; P = 0·108). The mean(s.d.) duration of required analgesia and the median (range) duration of postoperative hospital stay were significantly shorter in the LLR group: 3·0(1·1) days versus 1·6(0·8) days in the OLR group (P < 0·001), and 6 (3-44) versus 4 (1-11) days (P < 0·001), respectively. The 3-year recurrence-free survival rates for patients with hepatocellular carcinoma (37 per cent for OLR versus 30 per cent for LLR; P = 0·534) and those with colorectal liver metastases (36 versus 36 per cent respectively; P = 0·440) were not significantly different between the groups.

CONCLUSION

LLR of tumours in PS segments is feasible in selected patients. LLR is associated with fewer complications and does not compromise survival compared with OLR.

Role of laparoscopic enucleation in the treatment of pancreatic lesions: case series and case-matched analysis

BACKGROUND

Previous studies report successful application of laparoscopic pancreatic enucleation (LPE). However, the evidence is limited to small series. This study aimed to evaluate the indications, technique and outcome of LPE at a tertiary care institution.

METHODS

Between February 1998 and April 2016, 45 consecutive LPEs were performed at Oslo University Hospital-Rikshospitalet. Twenty-four (53.3 %) patients subjected to right-sided LPE (RLPE) were compared with 21 (46.7 %) patients who had undergone left-sided LPE (LLPE). A case-matched analysis (1:2) was performed to compare the outcomes following LLPE and laparoscopic distal pancreatectomy (LDP).

RESULTS

Patient demographics, BMI, ASA score and pathological characteristics were similar between the RLPE and LLPE groups. Operative time was slightly longer for RLPE [123 (53-320) vs 102 (50-373) min, P = 0.09]. The rates of severe morbidity (≥Accordion grade III) and clinically relevant pancreatic fistula (grades B/C) were comparable, although with a trend for higher rate of complications following LLPE (16.7 vs 33.3 %; P = 0.19 and 20.8 vs 33.3 %, P = 0.34, respectively). The hospital stay was similar between RLPE and LLPE [5 (2-80) vs 7 (2-52), P = 0.49]. A case-matched analysis demonstrated shorter operating time [145 (90-350) vs 103 (50-233) min, P = 0.02], but higher readmission rate following LLPE (25 vs 3.1 %, P = 0.037).

CONCLUSION

LLPE seems to be associated with a higher risk of postoperative morbidity and readmission rates than LDP. RLPE is a feasible, safe approach and a reasonable alternative to pancreatoduodenectomy in selected patients with pancreatic lesions.

Impact of obesity on surgical outcomes of laparoscopic distal pancreatectomy: A Norwegian single-center study

BACKGROUND

Obesity is known as a risk factor for intra- and postoperative complications in pancreatic operation. However, the operative outcomes in obese patients undergoing laparoscopic distal pancreatectomy remain unclear.

METHODS

A total number of 423 patients underwent laparoscopic distal pancreatectomy at Oslo University Hospital-Rikshospitalet from April 1997 to December 2015. Patients were categorized into 3 groups based on the body mass index: normal weight (18.5-24.9 kg/m²), overweight (25-29.9 kg/m²), and obese (≥30 kg/m²). After excluding underweight patients, 402 patients were enrolled in this study.

RESULTS

Obese patients had significantly longer operative time and increased blood loss compared with overweight and normal weight patients (190 [61-480] minutes vs 158 [56-520] minutes vs 153 [29-374] minutes, P = .009 and 200 [0-2,800] mL vs 50 [0-6250] mL vs 90 [0-2,000] mL, P = .01, respectively). A multiple linear regression analysis identified obesity as predictive of prolonged operative time and increased blood loss during laparoscopic distal pancreatectomy. The rates of clinically relevant pancreatic fistula and severe complications (≥grade III by Accordion classification) were comparable in the 3 groups (P = .23 and P = .37, respectively). A multivariate logistic regression model did not demonstrate an association between obesity and postoperative morbidity (P = .09). The duration of hospital stay was comparable in the 3 groups (P = .13).

CONCLUSION

In spite of longer operative time and greater blood loss, laparoscopic distal pancreatectomy in obese patients is associated with satisfactory postoperative outcomes, similar to those in normal weight and overweight patients. Hence, laparoscopic distal pancreatectomy should be equally considered both in obese and nonobese patients.

Validation of clinical risk scores for laparoscopic liver resections of colorectal liver metastases: A 10-year observed follow-up study

OBJECTIVE

The aim of this study was to validate clinical risk scores in patients underwent laparoscopic resection of colorectal liver metastases (CLM) with 5 years follow-up or more, and assess 5- and 10-year actual survival in this group.

METHODS

A total of 516 laparoscopic liver resections were performed in 406 patients with CLM between February 1998 and September 2015. A follow-up of 5 and 10 years could be assessed in 144 and 29 patients, respectively. The Fong score, pre- and postoperative Basingstoke Predictive Index (BPI), Nordlinger score, and Iwatsuki score were validated.

RESULTS

Five- and ten-year cancer-related actual survival was 54% and 32%, respectively. The Fong score, pre- and postoperative BPI and the Nordlinger score divided patients into risk groups with significant difference in survival between the groups. However, predicted 5-year survival rates were lower than the actual 5-year survival (mean difference in 17%,13%, 20%, and 30%, respectively).

CONCLUSION

The Fong score, pre- and postoperative BPI and the Nordlinger score systems can be used to predict survival for laparoscopically operated patients in the era of multimodal-treatment after adjusting of survival rates. The actual five- and 10-year survival after laparoscopic resection of CLM is similar to results previously published for open liver resection. J. Surg. Oncol. 2016;114:757-763. © 2016 Wiley Periodicals, Inc.

The impact of laparoscopic versus open colorectal cancer surgery on subsequent laparoscopic resection of liver metastases: A multicenter study

BACKGROUND

Laparoscopic liver surgery is expanding. Most laparoscopic liver resections for colorectal carcinoma metastases are performed subsequent to the resection of the colorectal primary, raising concerns about the feasibility and safety of advanced laparoscopic liver surgery in the context of an abdomen with possible postoperative adhesions. The aim was to compare the outcome of laparoscopic hepatectomy for colorectal metastases after open versus laparoscopic colorectal surgery.

METHODS

This observational, multicenter study reviewed 394 patients undergoing laparoscopic minor and major liver resection for colorectal carcinoma metastases. Main outcome measures were intraoperative unfavorable incidents and short-term results in patients who had previous open versus laparoscopic colorectal cancer surgery.

RESULTS

Three hundred six patients (78%) had prior open and 88 (22%) had prior laparoscopic colorectal resection. Laparoscopic major hepatectomies were undertaken in 63 (16%). Intraoperative unfavorable incidents during laparoscopic liver surgery were significantly higher among patients who had prior open colorectal surgery (26%) compared with the laparoscopic group (14%; P = .017). Positive resection margins and postoperative complications were not associated with the approach adopted for the resection of the primary cancer. On multivariate logistic regression analysis, intraoperative unfavorable incidents were associated significantly only with prior open colorectal surgery (odds ratio, 2.8; P = .006) and laparoscopic major hepatectomy (odds ratio, 2.4; P = .009).

CONCLUSION

Laparoscopic minor hepatectomy can be performed safely in patients who have undergone previous open colorectal surgery. Laparoscopic major hepatectomy after open colorectal surgery may be challenging. Careful risk assessment in the decision-making process is required not to compromise patient safety and to guarantee the expected benefits from the minimally invasive approach.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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