Short-term outcomes of laparoscopic extended hepatectomy versus major hepatectomy: a single-center experience

INTRODUCTION

Laparoscopic major hepatectomy (LMH) remains restricted to a few specialized centers and poses a challenge to surgeons performing laparoscopic resections. Laparoscopic extended resections are even more complex and rarely conducted.

METHODS

From a single-institution database, we compared the short-term outcomes of patients who underwent major and extended laparoscopic resections, stratifying the entire retrospective cohort into four groups: right hepatectomy, left hepatectomy, right extended hepatectomy, and left extended hepatectomy. Patient demographics, tumor characteristics, operative variables, and especially postoperative outcomes were evaluated.

RESULTS

250 patients underwent major and extended laparoscopic liver resections, including 160 right, 31 right extended, 36 left, and 23 left extended laparoscopic hepatectomies. The most common indication for resection was colorectal liver metastases (64%). Laparoscopic extended hepatectomy (LEH) showed significantly longer operative time, more blood loss, need for Pringle maneuver, conversion to open surgery, higher rates of liver failure, postoperative ascites, and intra-abdominal hemorrhage, R1 margins and length of stay when compared with the LMH group. Mortality rates were similar between groups. Multivariate analysis revealed intraoperative blood transfusion (OR = 5.1[CI-95%: 1.15-6.79]; p = 0.02) as an independent predictor for major complications.

CONCLUSIONS

LEH showed to be feasible, however with higher blood loss and significantly associated to major complications.

Comparison between laparoscopic liver resection and open liver resection in patients with hepatocellular carcinoma with portal vein tumor thrombosis

BACKGROUND

Recently, the outcomes of surgical treatment for advanced hepatocellular carcinoma (HCC) have improved. However, despite the technical advancements in laparoscopic liver resection (LLR), it is still not recommended as the standard treatment for HCC with portal vein tumor thrombosis (PVTT) because of the poor oncological outcomes. This study aims to compare the clinical outcomes of open liver resection (OLR) and LLR in patients with HCC with PVTT.

METHODS

A total of 86 patients with PVTT confirmed in the pathological report between January 2014 and December 2018, were enrolled. Short-term, postoperative, and long-term outcomes, including recurrence-free survival and overall survival rates, were evaluated.

RESULTS

No difference between the two groups, except for age, was detected. The median age in the laparoscopic group was significantly higher than that in the open group. Regarding the pathological features, the maximal tumor size was significantly larger in the OLR; other pathological factors did not differ. There was no significant difference between overall survival (OS) and recurrence-free survival (RFS). Vp3 PVTT (hazards ratio [HR] 6.1, 95% confidence interval [CI] 1.9-18.5), Edmondson grade IV (HR 4.7, 95% CI 1.7-12.9, p = 0.003), and intrahepatic metastasis (HR 3.9, 95% CI 2.1-7.2, p < 0.001) remained the unique independent predictors of recurrence-free survival according to a multivariate Cox proportional hazard regression analysis.

CONCLUSIONS

Laparoscopic liver resection for the management of HCC with PVTT provides the same short- and long-term results as those of the open approach.

Laparoscopic versus open liver resection for multiple hepatocellular carcinoma within and beyond the Milan criteria: An Eastern-Western propensity score-matched analysis

BACKGROUND

There is still little knowledge about the outcomes of laparoscopic liver resection (LLR) for multiple hepatocellular carcinomas (HCC). The aim of this study was to assess the short- and long- term outcomes of LLR versus open liver resection (OLR) for patients with multiple HCC within and beyond the Milan criteria, and in both BCLC-A and -B stage.

METHODS

Data regarding all consecutive patients undergoing liver resection for multiple HCC were retrospectively collected from Asian (South Korean) and European (Italian) referral HPB centers. The cases were propensity-score matched for age, BMI, center, extent of the resection, postero-superior location of the lesion, underlying liver condition, BCLB staging and the Milan criteria.

RESULTS

A total of 203 patients were included in the study: 27% of patients had undergone hemi-hepatectomy, 26.6% atypical resections, 20.6% sectionectomy and 16.2% segmentectomy. After PSM two cohorts of 57 patients were obtained, with no significant differences in all preoperative characteristics. The length of hospital stay was significantly lower after LLR (median 7 vs. 9 days, p < .01), with no statistically significant differences in estimated blood loss, operation time, transfusions, postoperative bile leak, ascites, severe complications and R1 resection rates. After a median follow-up of 61 (±7) months, there were no significant differences between OLR and LLR in both median OS (69 vs. 59 months, p = .74, respectively) and median DFS (12 vs. 10 months, p = .48, respectively).

CONCLUSION

LLR for multiple HCC can be safe and effective in selected cases and is able to shorten median hospital stay without affecting perioperative and long-term oncological outcomes.

Perioperative and long-term survival outcomes of laparoscopic versus open hepatectomy for BCLC stage A large hepatocellular carcinoma patients in difficult segments: A two-centre, propensity score matching analysis

Background

The differences in short- and long-term outcome between laparoscopic liver resection (LLR) and open liver resection (OLR) for BCLC stage A large hepatocellular carcinoma (HCC) in difficult segments (I, IVa, VII, VIII) remain unclear. This PSM two-centre study aimed to compare perioperative and long-term survival outcomes of LLR with OLR for this HCC.

Methods

HCC patients with BCLC stage A who underwent OLR or LLR in two medical centres were enrolled in the study. PSM analysis was performed to match patients between the LLR cohort and OLR cohort. Survival was analysed based on the Kaplan–Meier method. Independent risk factors were identified by Cox regression.

Results

After PSM, 35 patients remained in the LLR cohort, and 84 remained in the OLR cohort. Patients in the LLR cohort had more intraoperative blood loss (p=0.036) and shorter hospital stays after surgery (p&lt;0.001). The LLR cohort and OLR cohort had no difference in intraoperative blood transfusion, surgical margin or postoperative short-term outcomes. The OS and RFS were not significantly different between the two cohorts. The OS and RFS of these two cohorts were not different in the subgroup analysis. Surgical margin was identified as an independent risk factor for tumour recurrence.

Conclusion

For BCLC stage A large HCC patients with lesions in difficult segments, LLR was feasible and had shorter hospital stay than OLR. In addition, a surgical margin ≥1 cm could significantly decrease the recurrence probability for large HCC located in different segments without compromising short-term outcomes.

Hemihepatic versus total hepatic inflow occlusion for laparoscopic hepatectomy: A randomized controlled trial

BACKGROUND

An appropriate bleeding control technique for laparoscopic liver resection (LLR) is needed to decrease intraoperative blood loss and avoid large hemorrhages. To date, hemihepatic inflow occlusion (HIO) versus total hepatic inflow occlusion (TIO) for LLR is still controversial. Thus, we performed this randomized controlled trial (ChiCTR-IOR-17013866) to compare the perioperative outcomes between HIO and TIO for LLR.

METHODS

From December 2017 to August 2019, patients met the criteria via surgical exploration in the operation room and were randomly assigned to both groups. Perioperative data between both groups were recorded and compared, and subgroup analysis was further performed.

RESULTS

258 patients were allocated to the TIO (n = 129) and HIO (n = 129) groups, respectively. There was no significant difference between the two groups in terms of intraoperative blood loss, operative time, postoperative complications, changes in postoperative liver function or early mortality. However, for patients whose transection plane was located on the liver Cantlie's plane, subgroup analysis results indicated that TIO had a shorter operative time (median, 220 vs. 240 min, P = 0.030) and occlusion time (median, 45 vs. 60 min, P = 0.011) and less intraoperative blood loss (median, 200 vs. 300 ml, P = 0.002) than HIO, whereas the morbidity and mortality of the two groups were comparable.

CONCLUSION

Both the TIO and HIO approaches could be safely performed for LLR in selected patients when performed by experienced surgeons. The TIO technique for LLR had the advantage of being easier to master than the HIO approach. Additionally, when the transection plane was located on the liver Cantlie's plane, TIO seems to have some superior perioperative outcomes.

Laparoscopic versus open liver resection for resectable HCC with BCLC stage B: a propensity score-matched analysis

To date, there is little knowledge about the value of laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) patients with Barcelona Clinic Liver Cancer (BCLC) stage B. Thus, this study was performed to assess the perioperative and oncological outcomes of LLR for these patients by comparison with open liver resection (OLR). Between April 2015 and October 2018, a total of 217 resectable HCC patients with BCLC stage B were eligible for this study. Patients were divided into the LLR group and the OLR group according to different procedures. Propensity score matching (PSM) was conducted to adjust for known confounders. Short- and long-term outcomes were compared between the two groups. LLR was performed in 75 of the 217 included patients. After PSM, 72 patients with well-balanced baseline levels were enrolled into each group. Although the operative time was significantly longer in the LLR group than in the OLR group (median, 237.5 vs. 210 min, P = 0.024), the intraoperative blood loss was significantly less in the LLR group than in the OLR group (median, 200 vs. 350 ml, P = 0.005). Patients in the LLR group had fewer complications than those in the OLR group (P = 0.035). Furthermore, overall survival (OS, P = 0.827) and recurrence-free survival (RFS, P = 0.694) were comparable between the two groups. LLR for resectable HCC patients with BCLC stage B is safe and feasible in carefully selected patients and has superior perioperative outcomes and similar survival rates compared with OLR.

Laparoscopic versus open caudate lobe liver resections: a 1:2 propensity score-matched controlled study based on a single institution experience

BACKGROUND

Despite the wide use of laparoscopy for liver resection, laparoscopic caudate lobe resections(L-CLR) remain technically challenging, only attempted by experts in the field. The primary objective of this study was to determine the safety and compare the perioperative outcomes of L-CLR with O-CLR based on our single institution experience in a 1:2 propensity score-matched controlled study based on our single institution experience.

METHODS

Between 2004 and 2020, 67 consecutive patients who underwent CLR at Singapore General Hospital were identified. Propensity score matching (PSM) of laparoscopic versus open caudate lobe resections(O-CLR) was performed in a 1:2 ratio with no replacements using nearest neighbour matching method.

RESULTS

L-CLR was associated with a significantly decreased median blood loss (150 mL versus 500 mL, P = 0.001) and a decreased median post-operative stay (3 days versus 7.5 days, P = <0.01) in the unmatched cohorts. After 1:2 propensity score matching, these results were again demonstrated with a significantly lower blood loss (150 mL versus 400 mL, P = 0.016) and a shorter postoperative stay (3 days versus 7 days, P = <0.01) in favour of L-CLR. 30-day readmission and major morbidity (Clavien-Dindo grade > 2) rates were all in favour of L-CLR as well but could not reach statistical significance.

CONCLUSION

L-CLR can be safely performed by experienced surgeons. It is associated with decreased blood loss and shorter perioperative stay compared to O-CLR.

Long-Term Outcomes of Laparoscopic Liver Resection for Centrally Located Hepatocellular Carcinoma

Background and Objectives: The feasibility of laparoscopic liver resection (LLR) for centrally located hepatocellular carcinoma (cHCC 1 cm of the hilum, major hepatic veins, and inferior vena cava) is still controversial. This study aims to evaluate the feasibility and safety of LLR for cHCC and compare the perioperative outcomes with those of open liver resection (OLR). Materials and Methods: This retrospective study included 110 patients who underwent LLR (n = 59) or open liver resection (OLR) (n = 51) for cHCC between January 2004 and September 2018. LLR group was divided into the following two subgroups according to the date of operation: Group 1 (n = 19) and Group 2 (n = 40), to account for the advancement in the laparoscopic techniques. Results: No mortality within 3 months was observed. There were no significant differences in operation time (285 vs. 280 min; p = 0.938) and postoperative complication rate (22.0% vs. 27.5%; p = 0.510) between both groups. However, intraoperative blood loss (500 vs. 700 mL; p < 0.001), transfusion rate (10.2% vs. 31.4%; p = 0.006), and hospital stay (6 vs. 10 days; p < 0.001) were significantly lower in the LLR group than in the OLR group. In the LLR group, Group 2, showed a shorter hospital stay than Group 1 (6 vs. 8 days; p = 0.006). There were improvements in the operation time (280 vs. 360 min; p = 0.036) and less intraoperative blood loss (455 vs. 500 mL; p = 0.075) in Group 2. Conclusions: We demonstrated that LLR can be safely performed in highly selected patients with cHCC.

Lymphadenectomy and margin-negative resection for biliary tract cancer surgery in the United States-Differential technical performance by approach

BACKGROUND

As minimally invasive surgery (MIS) approaches to biliary tract cancers become more commonplace, understanding the adequacy of their oncologic performance is key.

METHODS

The National Cancer Database 2010-2016 was queried for patients who underwent hepatectomy for intrahepatic cholangiocarcinoma (IHC) and T1b or more advanced gallbladder cancer (GBC). Patients were grouped by approach: open (OA), laparoscopic (LA), and robotic (RA). Margin status, rate of lymph node (LN) dissection, and yield of LN dissection were evaluated.

RESULTS

This cohort of 8612 patients, including 4034 patients with IHC (OA: 3281, LA: 675, RA: 78) and 4578 patients with GBC (OA: 1893, LA: 2588, RA: 97), MIS was used 40% of the time. R0 resection was achieved in 82% OA, 84% LA, and 91% RA, p = 0.004. Rate of LN dissection was 53% (OA: 60%, LA: 42%, RA: 51%, p < 0.001). Among patients who underwent lymphadenectomy, 6 + LN were retrieved less commonly with a LA (OA: 27%, LA: 20%, and RA: 30%, p < 0.001). High-volume MIS hepatectomy centers were more likely to perform a lymphadenectomy (odds ratio [OR]: 1.41) and a sampling of 6 + LN (OR: 1.18).

CONCLUSION

Regardless of approach, lymphadenectomy is underperformed nationwide for biliary tract tumors, particularly with LA. As the use of MIS grows for the treatment of biliary tract cancers, scrutiny of oncologic outcomes is required.

Laparoscopic Anatomical Versus Non-anatomical hepatectomy in the Treatment of Hepatocellular Carcinoma: A randomised controlled trial

BACKGROUND

The choice of surgical modality for laparoscopic hepatectomy for hepatocellular carcinoma (HCC) has not been supported by high level of medical evidence hitherto. A prospective randomised controlled trial (RCT) was conducted to compare the perioperative and follow-up outcomes of patients with HCC treated by laparoscopic anatomical hepatectomy (LAH) and non-anatomical hepatectomy (LNAH).

METHODS

Between March 2013 and Jan 2018, eligible patients undergoing LAH and LNAH were enrolled and divided randomly into LAH group and LNAH group in this study. The perioperative and follow-up outcomes of both groups were compared and analyzed.

RESULTS

A total of 385 patients with HCC were randomly divided into LAH (n = 192) and LNAH (n = 193) groups. The groups were evenly matched for age, sex, liver background, segment involvement, tumor size, Child-Pugh grade and preoperative liver function. The operative time in the LAH group was longer than that of the LNAH group (p = 0.003). No significant between-group differences in intraoperative blood loss (p = 0.368), transfusion rate (p = 0.876), conversion to laparotomy rate (p = 0.365), overall complication rates (p = 0.054) were observed. The 1-year, 3-year and 5-year overall survival rates (OS) in the LAH group were 91.1%, 67.2%, 43.2%, respectively. The corresponding data in the LNAH group were 89.1%, 63.7%, and 35.2%, respectively. No significant difference was observed with regard to the 5-year OS rate (p = 0.054) between the two groups. The 1-year, 3-year and 5-year disease-free survival (DFS) rates in the LAH group were 87.0%, 54.7%, 33.9%, respectively. The corresponding data in LNAH group were 70.5%, 34.7%, and 30.1%, respectively. The 5-year DFS rate in the LAH group was significantly higher than that in the LNAH group (p = 0.009).

CONCLUSIONS

LAH versus LNAH for selected HCC patients was associated with increased DFS, lower intrahepatic ipsilateral recurrence rate, comparable long-term OS and postoperative complications. LAH is therefore recommended for selected HCC patients.

REGISTRATION NUMBER

NCT02009176 (https://www.

CLINICALTRIALS

gov/).

Is the anterior approach suitable for laparoscopic right hemihepatectomy in patients with large HCC (5-10 cm)? A propensity score analysis

BACKGROUND

Right hemihepatectomy via the anterior approach was initially employed to improve the survival of patients with large hepatocellular carcinoma (HCC). To date, the safety and feasibility of laparoscopic right hemihepatectomy via the anterior approach (ALRH) for patients with large HCC remains unclear; thus, we compared short-term and long-term outcomes between ALRH and open right hemihepatectomy via the anterior approach (AORH).

METHODS

161 patients with HCC who met the inclusion and exclusion criteria in our department were enrolled in this study between January 2015 and August 2018. Perioperative and oncological outcomes were compared using propensity score matching analysis (PSM).

RESULTS

There were 45 patients in the ALRH group and 116 patients in the AORH group. After 1:3 PSM, 40 ALRH patients and 95 AORH patients were well matched. The intraoperative time was longer in the ALRH group than in the AORH group after PSM (median, 297.5 vs. 205 min, P < 0.001). However, ALRH led to less intraoperative blood loss than AORH after PSM (median, 265 vs. 350 ml, P = 0.049). The rates of overall complications (12.5% vs. 30.5%, P = 0.028) in the ALRH group were significantly lower than those in the AORH group after PSM. Moreover, the survival outcomes were equivalent between the two groups with regard to 1-, 3-, and 5-year overall survival rates (P = 0.698) and disease-free survival rates (P = 0.510).

CONCLUSION

ALRH could be safe and feasible for some patients with large HCCs (5-10 cm) when performed by experienced surgeons, and it had superior perioperative outcomes and equivalent oncological outcomes to AORH.

Laparoscopic Versus Open Surgery for Early-Stage Intrahepatic Cholangiocarcinoma After Mastering the Learning Curve: A Multicenter Data-Based Matched Study

BACKGROUND

Surgical resection is the only widely accepted curative method for intrahepatic cholangiocarcinoma (ICC). However, little is known about the efficacy of laparoscopic liver resection for ICC, especially in patients with early-stage disease. The aim of this study was to compare the short-term and long-term effects of laparoscopy and open surgery for the treatment of ICC.

METHODS

Data from 1,084 patients treated at three hospitals from January 2011 to December 2018 were selected and analyzed. Propensity score matching was performed to compare the long-term outcomes (overall survival and recurrence-free survival) and short-term outcomes (perioperative outcomes) of all-stage and early-stage patients.

RESULTS

After matching, 244 patients (122 vs. 122) in the all-stage group and 65 patients (27 vs. 38) in the early-stage group were included. The baseline of the two groups was balanced, and no significant differences were found in sex or age. The short-term results of the laparoscopic group were better than those of the open group, including less blood loss [blood loss ≥400 ml 27 (22.1%) vs. 6 (4.92%), p<0.001 for all-stage, 12 (31.6%) vs. 2 (7.41%), p=0.042 for early stage), shorter surgery [200 (141; 249) min vs. 125 (115; 222) min, p=0.025 for early stage] and shorter hospital stay [11.0 (9.00; 16.0) days vs. 9.00 (7.00; 12.0) days, p=0.001 for all stage, 11.0 (8.50; 17.8) days vs. 9.00 (6.50; 11.0) days, p=0.011 for early stage]. Regarding long-term outcomes, no significant differences were found for all-stage patients, while there were significant differences observed for the early-stage group (p=0.013 for OS, p=0.014 for RFS). For the early-stage patients, the 1-, 3-, and 5-year OS rates of the OLR group were 84.2, 65.8, and 41.1%, respectively, and those of the LLR group were 100, 90.9, and 90.9%, respectively. The RFS rates of the OLR group were 84.2, 66.7, and 41.7%, respectively, and those of the LLR group were and 92.3, 92.3, and 92.3%, respectively.

CONCLUSION

Patients treated with laparoscopy seemed to have better short-term outcomes, such as less blood loss, shorter operation duration, and shorter hospital stay, than patients undergoing open surgery. Based on the long-term results, laparoscopic treatment for early ICC may have certain advantages.

Pure Laparoscopic Versus Open Approach for Living Donor Right Hepatectomy: A Systematic Review and Meta-Analysis

Background: Pure laparoscopic liver donor right hepatectomy (LLDRH) remains challenging, and its value is still unclear compared with open liver donor right hepatectomy (OLDRH). Objective: To provide comprehensive evidence about the safety and efficacy of LLDRH. Methods: The MEDLINE, Embase, Web of Science, and Cochrane Library electronic databases were searched from the date of inception to July 2021. A fixed-effects or random-effects model was used to analyze the pooled data by using Review Manager Version 5.3. Results: A total of 1940 patients from 6 studies were enrolled in this meta-analysis. For perioperative outcomes of donors, LLDRH had a longer operative time than OLDRH (weighted mean difference [WMD] = 29.75 [4.23-55.26] minutes, P = .02), but it had lower overall morbidity (odds ratio [OR] = 0.67 [0.45-0.99], P = .04), fewer pulmonary complications (OR = 0.47 [0.29-0.76], P = .002), and shorter hospital stays (WMD = -1, P < .001) than OLDRH. However, major complications, biliary complications, portal vein problems, and intra-abdominal bleeding were comparable between the 2 groups. With regard to the postoperative data of recipients, the risks of biliary problems, hepatic artery problems, portal vein problems, hepatic vein problems, and postoperative liver failure were similar between the 2 groups. Conclusions: LLDRH for living donors is safe and effective, and it offers superior perioperative outcomes to OLDRH.

Does laparoscopic hepatectomy offer benefits for patients with COPD? A propensity score analysis

BACKGROUND

To date, it remains unclear whether laparoscopic hepatectomy (LH) is safe and feasible for patients with chronic obstructive pulmonary disease (COPD). Thus, we compared the perioperative outcomes of LH versus open hepatectomy (OH) in this special cohort of patients.

METHODS

Between February 2014 and October 2020, 162 patients who underwent hepatectomy met the inclusion and exclusion criteria of this study. Perioperative data were compared between the two groups by propensity score matching (PSM) analysis.

RESULTS

After PSM, 55 patients with well-balanced baseline data were included in each group. Intraoperative blood loss, overall postoperative complications, and postoperative pulmonary complications (PPCs) were significantly lower in the LH group than in the OH group (P < 0.001, P = 0.047, and P = 0.020 after PSM, respectively). However, major complications, early readmission, and early mortality were comparable between the two groups. According to multivariate analysis, high stage of COPD, preoperative tobacco use, and long operative time were independent risk factors for PPCs, whereas treatment with LH was a protective factor.

CONCLUSION

LH is safe and feasible for selected patients with COPD when performed by experienced surgeons, and it has superior perioperative outcomes (especially regarding PPCs) when compared to OH.

Comprehensive analysis of laparoscopic, robotic, and open hepatectomy outcomes using the nationwide readmissions database

Although open resections have been the most prevalent method of hepatectomies in the United States, laparoscopic and robotic methods of liver resection have since gained significant traction. Given the augmenting role of minimally invasive techniques in liver resection, a study that explores and analyzes the surgical outcomes of the approaches mentioned above to liver resection on a national basis is warranted. A retrospective analysis was performed in this study using the 2016-2018 Nationwide Readmissions Database (NRD). Patients who underwent liver resections via one of the following methods were selected and grouped: open, laparoscopic, or robotic. Our primary outcome variable of interest was the 45-day readmission rate. 11,186 patients were included in the analysis. The 45-day readmission rate was 13.5%, 12.9%, and 8.7% in the open, laparoscopic, and robotic groups, respectively (p < 0.001). A significantly lower complication rate (7.3%) was seen in the robotic group than its counterparts (11.4% in open vs. 9.1% in the laparoscopic group). Patients undergoing hepatectomies may benefit from the robotic approach given that it is associated with a shorter hospital length of stay and lower readmission rates.

Hospitalization Costs and Outcomes of Open, Laparoscopic, and Robotic Liver Resections

INTRODUCTION

Most liver resections performed in the United States are open. With the ever-increasing role of robotic surgery, our study's role is to assess national outcomes based on the surgical approach.

METHODS

We performed a retrospective analysis of the 2015 National Readmission Database (NRD). We selected patients undergoing open, laparoscopic, and robotic hepatectomy. Propensity score matching was performed to match the three groups in terms of demographics, hospital characteristics, and resection type. Our primary outcome was 6-month readmission rates and associated costs.

RESULTS

3,872 patients were included in the analysis (open = 3,420, laparoscopic = 343, and robotic = 109). Robotic liver resection has lower 6-month readmission rates (18.3%) than the laparoscopic (26.7%) and open (30%) counterparts. The robotic approach was more cost-effective ($127,716.56 ± 12,567.31) than the open ($157,880.82 ± 18,560.2) and laparoscopic approach ($152,060.78 ± 8,890.13) in terms of the total cost which includes cost per readmission.

CONCLUSIONS

There is a financial benefit of using robotics in terms of cost, hospital length of stay, and readmission rates in patients undergoing liver resection, cost.

Laparoscopic hepatectomy versus open hepatectomy for tumors located in right posterior segment: A single institution study

OBJECT

With the gradual advancement of laparoscopic technology, surgeries can be successfully performed with the help of laparoscopy increasingly. This study initially explored the difference between laparoscopic right posterior sectionectomy (LRPS) and open right posterior sectionectomy (ORPS)of liver in our center, discussed the effectiveness, benefits and safety of LRPS and introduce some surgical techniques in our center.

MATERIALS AND METHODS

We retrospectively analyze 96 cases of liver tumor located in the right posterior lobe of liver in our institution from January 2015 to January 2018. There were 46 cases performed the LRPS surgery and 50 cases performed the ORPS surgery. Through analysis of the perioperative outcomes of these two groups by a case control study, we compare the differences between these two groups.

RESULTS

There was no significant difference between the LRPS and ORPS group in demographic and baseline characteristics before surgery. Patients in the LRPS group were significantly superior to ORPS in terms of postoperative liver function recovery, postoperative inflammatory factor level, pain sensation (3.03 ± 0.79 vs 4.58 ± 1.25), abdominal incision length (6.25 ± 2.34 vs 32.15 ± 3.21), carrying abdominal drainage tube time (3.26 ± 0.77 vs 4.83 ± 0.76), recovery of bowel function time (1.6 ± 0.61 VS 3.05 ± 0.85)and postoperative hospital stay (5.73 ± 0.99 vs 7.16 ± 0.95) (P < 0.05).

CONCLUSION

Compared with the traditional ORPS, LRPS has the advantages of minor injury, faster recovery and mild inflammatory reaction. The LRPS is safe and feasible, and it should be gradually promoted in clinical practice.

Evaluation of accuracy of laparoscopic liver mono-segmentectomy using the Glissonian approach with indocyanine green fluorescence negative staining by comparing estimated and actual resection volumes: A single-center retrospective cohort study

BACKGROUND/PURPOSE

Laparoscopic liver mono-segmentectomy (LLMS) may improve patient outcomes, but it is difficult and its accuracy and safety are unknown. We evaluated the accuracy of LLMS using Glissonian approach with indocyanine green fluorescence (ICG) negative staining.

METHODS

Seventy-four patients eligible for LLMS except for segment 1 were enrolled. Preoperative three-dimensional CT-based surgical simulation was used to determine estimated liver resection volume (ELRV), which was compared with modified actual liver resection volume (ALRV) obtained from actual liver resection mass. The LLMS accuracy was also evaluated based on operator's experience (attending surgeon [AS] or trainee surgeon [TS]).

RESULTS

Estimated liver resection volumes significantly correlated with ALRVs (r = .82) in all cases. Moreover, TS-conducted LLMS also showed acceptable difference between ELRV and ALRV compared with AS-conducted LLMS. There were no intergroup differences in estimated blood loss, operation time, time of Pringle maneuver, postoperative complications, and length of postoperative hospitalization (P < .05). Moreover, R0 resection was comparable between the AS and TS groups.

CONCLUSIONS

Laparoscopic liver mono-segmentectomy with Glissonian approach using ICG negative imaging ensured safe and accurate procedure owing to facilitated visualization of the resection line. Our approach was effective in avoiding postoperative liver dysfunction and securing radical resection. In addition, it might be helpful in TS education of LLMS.

Propensity score matching analysis for outcomes of laparoscopic versus open caudate lobectomy

BACKGROUND

To date, laparoscopic caudate lobectomy (LCB) remains a challenge, and evidence about its value is rare. Therefore, this study was performed to assess the benefits of LCB for patients with tumours located in the caudate lobe compared with open caudate lobectomy (OCB).

METHODS

From October 2015 to June 2019, 102 patients meeting the inclusion and exclusion criteria were eligible for this study. The patients were divided into LCB and OCB groups. Short-term outcomes between the groups were compared with propensity score matching (PSM).

RESULTS

LCB was performed in 31 of the 102 included patients. After PSM, 30 patients with well-balanced baseline levels were enrolled in each group. Intraoperative blood loss in the LCB group was less than that in the OCB group (median, 100 versus 200 mL, P = 0.017), even though it did not reach a statistically significant difference after PSM (median, 100 versus 187.5 mL, P = 0.085). Moreover, although post-operative overall complications were similar in the two groups, a tendency of lower rates of respiratory infection in the LCB group than the OCB group was observed (0% versus 12.7%, P = 0.054 before PSM; 0% versus 16.7%, P = 0.063 after PSM). There was no early mortality in either group. LCB had a shorter post-operative hospital stay than OCB (median, 5 versus 6 days, P < 0.001). However, the hospitalization cost was higher in the LCB group than in the OCB group (P < 0.001).

CONCLUSION

LCB is safe and feasible in selected patients when performed by experienced surgeons.

Major Laparoscopic Versus Open Resection for Hepatocellular Carcinoma: A Propensity Score-Matched Analysis Based on Surgeons' Learning Curve

BACKGROUND

Surgical complications for surgeons still in the learning phase of major laparoscopic liver resection (LLR) have been frequently observed. We aimed to compare perioperative and long-term outcomes of laparoscopic and open surgery based on the surgeons' learning curve for LLR after propensity score-matched (PSM) analysis.

METHODS

This was a retrospective study of all patients with a histologic diagnosis of hepatocellular carcinoma who underwent major hepatectomy between January 2013 and December 2018. A PSM analysis was used to compare the groups of patients who underwent LLR and open major liver resection (OLR) before and after the learning curve was maximized.

RESULTS

Among 405 patients, 106 underwent LLR and 299 underwent OLR. The learning curve was maximized after 42 cases. Compared with OLR, LLR had more liver-related injury and grade III or higher complications during the learning phase. The LLR group had less blood loss, fewer transfusion requirements, and fewer liver-related complications during the 'experienced' phase. Hospital stay was significantly shorter during and after maximization of the learning curve in LLR compared with OLR. Operative time was comparable in the two phases. Overall, LLR was associated with less blood loss, fewer complications, and shorter hospital stay compared with open surgery. There was no significant difference in long-term survival outcomes between the two groups.

CONCLUSIONS

LLR had a higher incidence of liver-related complications during the surgeon's learning phase compared with OLR. This association was significantly diminished with surgeon experience. Overall perioperative outcomes such as estimated blood loss, surgical complications, and hospital stay remained better for LLR compared with OLR.

Is laparoscopic liver resection suitable for selected patients with BCLC stage B HCC? A propensity score-matched analysis

BACKGROUND

The optimal treatment for patients with Barcelona Clinic Liver Cancer (BCLC) stage B hepatocellular carcinoma (HCC) is controversial given the variability of tumour status within this group of patients. This aim of this study was to compare the outcomes of laparoscopic liver resection (LLR) to transarterial chemoembolization (TACE) in a subset of selected patients with BCLC stage B HCC.

METHODS

Patients with resectable BCLC stage B HCC who underwent treatment between April 2015 and October 2018 were identified for further analysis. Propensity score matching (PSM) was conducted to minimize effect of confounding factors. Perioperative and long-term outcomes were compared between the two groups and multivariate analysis was performed to identify risk factors related to the overall survival (OS).

RESULTS

From a total of 224 patients 70 were included into each group after PSM. The overall and major morbidity were comparable between the LLR and TACE groups (P = 0.700 and P = 0.500 after PSM, respectively). The OS in LLR group was significantly better than that in the TACE group (P < 0.001). Tumor number ≥4, the diameter of the biggest tumor >5 cm, and patients who underwent TACE were independent predictors of poorer OS.

CONCLUSIONS

LLR for selected patients with BCLC stage B HCC is safe and feasible and has improved survival as compared to TACE.

Hepatocellular carcinoma surgical and oncological trends in a national multicentric population: the HERCOLES experience

Liver surgery is the first line treatment for hepatocarcinoma. Hepatocarcinoma Recurrence on the Liver Study (HERCOLES) Group was established in 2018 with the goal to create a network of Italian centres sharing data and promoting scientific research on hepatocellular carcinoma (HCC) in the surgical field. This is the first national report that analyses the trends in surgical and oncological outcomes. Register data were collected by 22 Italian centres between 2008 and 2018. One hundred sixty-four variables were collected, regarding liver functional status, tumour burden, radiological, intraoperative and perioperative data, histological features and oncological follow-up. 2381 Patients were enrolled. Median age was 70 (IQR 63-75) years old. Cirrhosis was present in 1491 patients (62.6%), and Child-A were 89.9% of cases. HCC was staged as BCLC0-A in almost 50% of cases, while BCLC B and C were 20.7% and 17.9% respectively. Major liver resections were 481 (20.2%), and laparoscopy was employed in 753 (31.6%) cases. Severe complications occurred only in 5%. Postoperative ascites was recorded in 10.5% of patients, while posthepatectomy liver failure was observed in 4.9%. Ninety-day mortality was 2.5%. At 5 years, overall survival was 66.1% and disease-free survival was 40.9%. Recurrence was intrahepatic in 74.6% of cases. Redo-surgery and thermoablation for recurrence were performed up to 32% of cases. This is the most updated Italian report of the national experience in surgical treatment for HCC. This dataset is consistently allowing the participating centres in creating multicentric analysis which are already running with a very large sample size and strong power.

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

BACKGROUND AND AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Beneficial impact of microwave ablation-assisted laparoscopic hepatectomy in cirrhotic hepatocellular carcinoma patients: a propensity score matching analysis

PURPOSE

In this study, we evaluated the efficacy of microwave ablation-assisted laparoscopic hepatectomy (MLH) for the management of hepatocellular carcinoma (HCC) in cirrhotic patients.

METHODS

Data from HCC patients with liver cirrhosis who underwent laparoscopic hepatectomy (LH) or MLH in Shengjing Hospital (Shenyang, China) were retrospectively analyzed from January 2013 to June 2017. The demographic characteristics, clinical features, intraoperative parameters and surgical outcomes were analyzed and compared. Propensity scores matching (PSM) analysis was used to minimize bias.

RESULTS

A total of 54 patients were enrolled in the MLH group and 39 patients in the LH group. Following 1:1 matching by PSM analysis, 26 patients were selected from each group. Compared to the LH group, patients in the MLH group had significantly decreased intraoperative bleeding (48.0 vs. 203.9 ml, p < .0001) and reduced demand for hepatic inflow occlusion (0 vs. 6, p = .009). No significant difference was observed in average operation time (155.7 vs. 148.5 min) and postoperative hospitalization time (8.3 vs. 9.3 d) between the MLH and LH groups. Similarly, the 1-year and 3-year recurrence-free survival (RFS) rates as well as the 1-year and 3-year overall survival (OS) rates of the MLH and LH groups were not significantly different (83.1 vs. 82.4% and 64.6 vs. 36.6% as well as 100 vs. 95.8% and 93.8 vs. 59.1%, respectively: p > .05).

CONCLUSIONS

MLH significantly decreased intraoperative bleeding and reduced the need for hepatic occlusion without compromising the surgical outcome. Therefore, microwave ablation could be a valuable tool for LH in HCC patients with cirrhosis.

Safety and feasibility of laparoscopic liver resection for patients with large or multiple intrahepatic cholangiocarcinomas: A propensity score based case-matched analysis from a single institute

Only a few high-volume centers have reported the efficacy of laparoscopic liver resection (LLR) for patients with intrahepatic cholangiocarcinoma (ICC). The minimally invasive approach is still controversial for ICC, especially when dealing with large (≥5 cm) or multiple (≥2) ICCs.Patients with large and multiple ICCs who underwent LLR or open hepatectomy (OH) between January 2012 and June 2017 were included. Furthermore, 1:2 propensity score matching (PSM) was performed between the LLR group and the OH group. Short- and long-term outcomes were compared between the different techniques.After PSM, LLR resulted in significantly longer operation time (median 225 minutes vs 190 minutes, P = .006) and pringle maneuver time (median 50 minutes vs 32.5 minutes, P = .001). There was no statistically significant difference in postoperative hospital stay between the different approaches (median 6 days vs 7 days, P = .092). The grade III/IV complication rates were comparable between the groups (5.6% vs 11.1%, P = .868). In the PSM subset, there was no significant difference in terms of overall survival (P = .645) or disease-free survival (P = .827) between patients in the LLR group and in the OH group.The present study showed that patients who underwent LLR for large or multiple ICCs could obtain similar short- and long-term outcomes compared with those who underwent OH, and lymph node dissection (LND) was technically difficult but feasible during LLR.

Endoscopic hepatic resection and endoscopic radiofrequency ablation as initial treatments for hepatocellular carcinoma within the Milan criteria

PURPOSES

The indication of endoscopic (laparoscopic and thoracoscopic) hepatic resection (HR) has been expanded in the past decade because of its low invasiveness. However, the indications of endoscopic HR and radiofrequency ablation (RFA) have not yet been determined.

METHODS

Among the 906 patients hospitalized for the initial treatment of hepatocellular carcinoma (HCC) between 2000 and 2017, 77 underwent endoscopic partial HR (E-pHR), and 94 underwent endoscopic RFA (E-RFA). We compared the short- and long-term outcomes between the E-pHR and E-RFA groups.

RESULTS

The patients in the E-RFA group were characterized primarily by an impaired liver function. Among the patients with liver damage B or C, the overall survival (OS) in the E-pHR group was significantly worse than in the E-RFA group (3-year OS: 36% vs. 82%, p = 0.003).

CONCLUSION

E-RFA may be recommended for the initial treatment of HCC in patients with a severely impaired liver function. However, E-pHR should be avoided as the initial treatment of HCC in such patients.

Outcomes of laparoscopic repeat liver resection for recurrent liver cancer: A system review and meta-analysis

BACKGROUND

With the improvements of surgical instruments and surgeons' experience, laparoscopic liver resection has been applied for recurrent tumors. However, the value of laparoscopic repeat liver resection (LRLR) is still controversial nowadays, which compelled us to conduct this meta-analysis to provide a comprehensive evidence about the efficacy of LRLR for recurrent liver cancer.

METHODS

A computerized search was performed to identify all eligible trials published up to April 2019. This meta-analysis was conducted to estimate the perioperative data and oncological outcomes of LRLR by compared with open repeat liver resection (ORLR) and laparoscopic primary liver resection (LPLR). A fixed or random-effect modal was established to collect the data.

RESULTS

A total of 1232 patients were included in this meta-analysis (LRLR: n = 364; ORLR: n = 396; LPLR: n = 472). LRLR did not increase the operative time compared to ORLR (WMD = 15.92 min; 95%CI: -33.53 to 65.37; P = .53). Conversely, LRLR for patients with recurrent tumors was associated with less intraoperative blood loss (WMD = -187.33 mL; 95%CI: -249.62 to -125.02; P < .00001), lower transfusion requirement (OR = 0.24; 95%CI: 0.06-1.03; P = .05), fewer major complications (OR = 0.42; 95%CI: 0.23-0.76; P = .004), and shorter hospital stays (WMD = -2.31; 95%CI: -3.55 to -1.07; P = .0003). In addition, the oncological outcomes were comparable between the two groups. However, as for the safety of LRLR compared with LPLR, although the operative time in LRLR group was longer than LPLR group (WMD = 58.63 min; 95%CI: 2.99-114.27; P = .04), the blood loss, transfusion rates, R0 resection, conversion, postoperative complications, and mortality were similar between the two groups.

CONCLUSIONS

LRLR for recurrent liver cancer could be safe and feasible in selected patients when performed by experienced surgeons.

Outcomes of Laparoscopic Liver Resection for Patients with Multiple Hepatocellular Carcinomas Meeting the Milan Criteria: A Propensity Score-Matched Analysis

Background: Until now, there is little knowledge about the value of laparoscopic liver resection (LLR) for patients with multiple hepatocellular carcinomas (HCC). This study was performed to assess the efficacy and outcomes of LLR versus open liver resection (OLR) for patients with multiple HCC meeting the Milan criteria.

Methods: One hundred fifteen patients with multiple HCC meeting the Milan criteria who underwent liver resection from April 2015 to March 2018 were enrolled into this study. According to the different surgical procedures, patients were divided into LLR group and OLR group. Perioperative and oncological outcomes were compared between the two groups after propensity score matching (PSM) with 1:1 match.

Results: Thirty three patients were included into each group after PSM with well-balanced basic level. The intraoperative blood loss in LLR group was less than OLR group before PSM (median, 200 vs. 300 mL, P = .004), but the difference was not statistically significant after PSM (median, 200 vs. 300 mL, P = .064). LLR group showed shorter postoperative hospital stay when compared with OLR group (median, 7 vs. 8 days, respectively, P = .014). The perioperative complications and early mortality were comparable in both groups. There were no significant differences in the term of overall survival (OS. P = .502) or recurrence-free survival (RFS. P = .887) between the two groups after PSM.

Conclusions: LLR could be safely and feasibly performed for patients with multiple HCC meeting the Milan criteria in selected patients. It does not increase the risks of postoperative complications and has a similar oncological outcomes compared to OLR.

Intention to Treat Laparoscopic Versus Open Hemi-Hepatectomy: A Paired Case-Matched Comparison Study

BACKGROUND

The benefits of laparoscopic hemi-hepatectomy compared to open hemi-hepatectomy are not clear.

OBJECTIVE

This study aims to share our experience with the laparoscopic hemi-hepatectomy compared to an open approach.

METHODS

A total of 40 consecutive laparoscopically started hemi-hepatectomy (intention-to-treat analysis) cases between August 2012 and October 2015 were matched against open cases using the following criteria: laterality of surgery and pathology (essential criteria); American Society of Anesthesiologists score, body mass index, pre-operative bilirubin, neo-adjuvant chemotherapy, additional procedures, portal vein embolization, and presence of cirrhosis/fibrosis on histology (secondary criteria); age and gender (tertiary criteria). Hand-assisted and extended hemi-hepatectomy cases were excluded from the study. The two groups were compared for blood loss, operative time, hospital stay, morbidity, mortality, and oncological outcomes. All complications were quantified using the Clavien-Dindo classification.

RESULTS

Two groups were well matched (p = 1.00). In the two groups, 10 patients had left and 30 had right hemi-hepatectomy. Overall conversion rate was 15%. Median length of hospital and high dependency unit stay was less in the intention to treat laparoscopic hemi-hepatectomy group: 6 versus 8 days, p = 0.025 and 1 versus 2 days, p = 0.07. Median operative time was longer in the intention to treat laparoscopic hemi-hepatectomy group: 420 min (range: 389.5-480) versus 305 min (range: 238.8-348.8; p = 0.001). Intra-operative blood loss was equivalent, but the overall blood transfusions were higher in the intention to treat laparoscopic hemi-hepatectomy (50 vs 29 units, p = 0.36). The overall morbidity (18 vs 20 patients, p = 0.65), mortality (2.5%), and the positive resection margin status were similar (18% vs 21%, p = 0.76). The 1- (87.5% vs 92.5%, p = 0.71) and 3-year survival (70% vs 72.5%, p = 1.00) was also similar.

CONCLUSIONS

We observed lower hospital and high dependency unit stay in the laparoscopic group. However, the laparoscopic approach was associated with longer operating time and a non-significant increase in blood transfusion requirements. There was no difference in morbidity, mortality, re-admission rate, and oncological outcomes.

Surgical outcomes between patients with and without a cirrhotic liver undergoing laparoscopic liver resection: A meta-analysis

BACKGROUND

Laparoscopic surgery in patients with liver cirrhosis (CL) is considered to be challenging. Recent studies have shown that laparoscopic liver resection (LLR) is more beneficial of reduced operative stress and postoperative complications in patients with CL.

AIM

A meta-analysis was done to review the currently available published data comparing LLR for patients with CL versus those non-cirrhosis of the liver (NCL).

METHODS

The electronic databases of PubMed, Wiley, Web of Science, Embase, and the Cochrane Library were searched from date of inception to January 29, 2018. Studies reporting a comparison of outcomes and methods of LLR in CL and NCL groups were included. The studies were evaluated using the modified Newcastle-Ottawa Scale.

RESULTS

A total of 1573 patients from six cohort studies were included in final analysis. The CL group had a slightly shorter operative time compared with the NCL group (weighted mean difference [WMD], 18.78min shorter; 95% confidence interval [CI], -43.54-5.98; P=0.14) and delayed hospital stay (WMD, 1.26 days longer; 95% CI, -0.05-2.56; P=0.06). Blood loss, blood transfusion rate, mortality, and conversion rate did not differ significantly between the groups.

CONCLUSIONS

LLR is safe and feasible in the CL compared with the NCL groups. Our present review indicates that LLR should be considered when selecting surgery for patients with CL.

Laparoscopic versus open mesohepatectomy for patients with centrally located hepatocellular carcinoma: a propensity score matched analysis

BACKGROUND

Although laparoscopic mesohepatectomy (LM) has been performed for patients with centrally located hepatocellular carcinoma (CL-HCC), its short- and long-term benefits compared with traditional open surgery remain unclear. The aim of the present study was to explore the independent role of LM in the prognosis of patients with CL-HCC.

METHODS

A retrospective analysis was undertaken of 348 patients who underwent mesohepatectomy for CL-HCC between January 2012 and October 2017 in our hospital. The impact of the surgical methods on long-term prognosis was evaluated by multivariable regression analysis. In addition, patients in the LM group were matched in a 1:3 ratio with open mesohepatectomy (OM) group.

RESULTS

Some 307 patients underwent OM and 41 had LM. In both adjusted and non-adjusted models, patients in LM group had similar overall survival (OS, both P > 0.05) and disease-free survival (DFS, both P > 0.05) compared to OM patients. The mean (s.d.) OS in LM and OM groups was 41.6 (7.2) and 46.4 (1.4) months, respectively. The mean (s.d.) DFS in LM and OM groups was 37.7 (5.9) and 33.4 (1.5) months, respectively. After propensity score-matched (PSM) analysis, 96 patients remained in OM group and 32 patients in LM group. In the PSM subset, patients in LM group still had comparable OS (P = 0.120) and DFS (P = 0.757) compared to patients in the OM group. After PSM, patients receiving LM had longer vascular exclusion time (P = 0.006) and shorter hospital stay (P = 0.004). In addition, LM was associated with reduced postoperative morbidity after PSM adjustment (P = 0.026).

CONCLUSIONS

LM is associated with fewer complications and does not compromise survival compared with OM. LM can be recommended as a safe and reasonable surgical option in selected patients with CL-HCC.

Nationwide outcomes and costs of laparoscopic and robotic vs. open hepatectomy

The safety of hepatectomy continues to improve and it holds a key role in the management of benign and malignant hepatic lesions. Laparoscopic and robotic approaches to hepatectomy are increasingly utilized. The purpose of this study was to compare outcomes and costs of laparoscopic and robotic vs. open approaches to hepatectomy and to determine the national nonelective postoperative readmission rate, including readmission to other hospitals. The Nationwide Readmission Database from 2013 to 2014 was queried for all patients undergoing hepatectomy. Patients undergoing laparoscopic and robotic hepatectomies were compared to patients undergoing open hepatectomy. Multivariate logistic regression was implemented to determine the odds ratios (OR) for non-elective readmission within 45 days. There were 10,870 patients who underwent hepatectomy from 2013 to 2014 and 724 (6.7%) were approached with laparoscopic or robotic technique. The robotic cohort had lower mean cost of the index admission ($24,983 ± $18,329 vs. open $32,391 ± $31,983, p < 0.001, 95% CI - 18,292 to 534), shorter LOS (4.5 ± 3.8 vs. lap 6.8 ± 6.0 vs. open 7.6 ± 7.7 days, p < 0.01), and were less likely to be readmitted within 45 days (7.9% vs. 13.0% lap vs. 13.8% open, p = 0.05). The robotic cohort was slightly younger (mean age 57.5 ± 13.5 vs. lap 60.1 ± 13.8 vs. open 58.9 ± 13.7, p < 0.05), and no significant differences were seen by Charlson Comorbidity Index. Anastomosis of hepatic duct to GI tract carried higher odds of mortality (OR 2.87, p < 0.01) and higher odds of readmission (OR 1.40, p < 0.01). LOS above 7 days increased odds of readmission (OR 2.24, p < 0.01). Nearly one-fifth of patients readmitted after hepatectomy present to a different hospital. Robotic hepatectomy was associated with favorable cost and readmission outcomes compared to laparoscopic and open hepatectomy patients, despite similar patient comorbid burdens and patient's age. Length of stay over 7 days and anastomosis of hepatic duct to GI tract are strong risk factors for readmission and mortality.

Resection for hepatocellular cancer: overpassing old barriers

Several recent studies have shown that the selection limits commonly used for patients with hepatocellular cancer (HCC) potentially requiring a liver resection (LR) are too restrictive. The present review aims at investigating the studies showing that LR is no longer a treatment suitable only for highly selected patients, but also for patients selectively presenting one-to-more negative factors. Several specific variables have been investigated, none of them showing to be an absolute contraindication for LR: age; single vs. multiple diseases; the dimension of the nodule; hyperbilirubinemia; clinically relevant portal hypertension; Child-Pugh status; macrovascular invasion. As a consequence, LR for the treatment of HCC-on-cirrhosis is a safe and effective procedure not only in "ideal cases", but also for selected patients presenting risk factors. The presence of only one of these factors does not represent an absolute contraindication for LR. On the opposite, the contemporaneous presence of risk factors should contraindicate the procedure. Further studies investigating the "borderline" cases are required, mainly looking at the possible decisive role of laparoscopy in this setting.

OPEN, LAPAROSCOPIC, AND ROBOTIC-ASSISTED HEPATECTOMY IN RESECTION OF LIVER TUMORS: A NON-SYSTEMATIC REVIEW

Introduction:

Several factors have made hepatectomy an increasingly safe surgery and new drugs allowed surgical treatment for patients who initially were not candidates for resection. Lesions often require resection, which can be performed by open, laparoscopic, or robotic assisted hepatectomy.

Aim:

Compare the surgical techniques in open, laparoscopic, and robotic assisted hepatectomy for resection of liver tumors.

Methods:

Literature review based on scientific papers published on Lilacs/Pubmed/Scielo in the last 17 years regarding the indications of these techniques for liver tumor resections and on papers comparing such techniques.

Results:

The comparative study shows the benefits of laparoscopic surgery over open surgery, such as smaller incisions, less postoperative pain, shorter recovery time, smaller immune and metabolic response, and quicker restoration of oral ingestion as well as lower morbidity rates. However, the need for a specialized surgical team and the reduction in handling area still remain as disadvantages in the laparoscopic technique. It is yet not clear whether robotic assistance presents considerable benefits over the laparoscopic technique considering that high acquisition and maintenance costs are limiting factors.

Conclusion:

Despite all challenges, laparoscopic hepatectomy presents many benefits over open surgery. The robotic assisted technique is still in evolution as many centers in the world perform hepatic resections with the platforms but only after a thorough patient selection. Thus, laparoscopy stands as the best option, unless there is some contraindication to the procedure.

Laparoscopic right posterior sectionectomy versus laparoscopic right hemihepatectomy for hepatocellular carcinoma in posterior segments: Propensity Score Matching Analysis

BACKGROUND AND AIMS:

This study was designed to analyze the feasibility of laparoscopic right posterior sectionectomy compared to laparoscopic right hemihepatectomy in patients with hepatocellular carcinoma located in the posterior segments.

MATERIAL AND METHODS:

The study included patients who underwent either laparoscopic right posterior sectionectomy or laparoscopic right hemihepatectomy for hepatocellular carcinoma located in segment 6 or 7 from January 2009 to December 2016 at Samsung Medical Center. After 1:1 propensity score matching, patient baseline characteristics and operative and postoperative outcomes were compared between the two groups. Disease-free survival and overall survival were compared using Kaplan-Meier log-rank test.

RESULTS:

Among 61 patients with laparoscopic right posterior sectionectomy and 37 patients with laparoscopic right hemihepatectomy, 30 patients from each group were analyzed after propensity score matching. After matching, baseline characteristics of the two groups were similar including tumor size (3.4 ± 1.2 cm in laparoscopic right posterior sectionectomy vs 3.7 ± 2.1 cm in laparoscopic right hemihepatectomy, P = 0.483); differences were significant before matching (3.1 ± 1.3 cm in laparoscopic right posterior sectionectomy vs 4.3 ± 2.7 cm in laparoscopic right hemihepatectomy, P = 0.035). No significant differences were observed in operative and postoperative data except for free margin size (1.04 ± 0.71 cm in laparoscopic right posterior sectionectomy vs 2.95 ± 1.75 cm in laparoscopic right hemihepatectomy, P < 0.001). Disease-free survival (5-year survival: 38.0% in laparoscopic right posterior sectionectomy vs 47.0% in laparoscopic right hemihepatectomy, P = 0.510) and overall survival (5-year survival: 92.7% in laparoscopic right posterior sectionectomy vs 89.6% in laparoscopic right hemihepatectomy, P = 0.593) did not differ between the groups based on Kaplan-Meier log-rank test.

CONCLUSION:

For hepatocellular carcinoma in the posterior segments, laparoscopic right posterior sectionectomy was feasible compared to laparoscopic right hemihepatectomy when performed by experienced laparoscopic surgeons.

[Identical oncological results with lower perioperative morbidity after laparoscopic liver resection : Results of a matched pair analysis]

BACKGROUND

Laparoscopic liver resection belongs to the standard repertoire in hepatobiliary surgery. The advantages and disadvantages are still the subject of controversial discussion.

OBJECTIVE

The aim of the study was to compare the perioperative and long-term outcomes of laparoscopic and open liver resections.

MATERIAL AND METHODS

All patients who underwent liver resection in the Department of Surgery at the certified liver center of the  municipal hospital Karlsruhe were analyzed. From a total of 268 hepatic resections 65 laparoscopic liver resections were identified and matched 1:1 with 65 open resections, based primarily on the extent of the resection and secondarily on diagnosis, age and gender of the patients. The demographic data, comorbidities, perioperative and long-term outcomes were compared.

RESULTS

Both groups had comparable demographic parameters and comorbidities. Operation time, duration of intensive care stay and percentage of negative resection margins were comparable in both groups. The 30-day mortality was 0% and 90-day mortality 1.5% in both groups. The laparoscopic group showed lower intraoperative and postoperative transfusion rates (p < 0.001), shorter hospital stay (p < 0.001) and lower overall morbidity (p < 0.001). The 1-, 3- and 5-year overall and tumor-free survival of patients with colorectal liver metastases was comparable (p = 0.984; p = 0.947). The same applied for patients with hepatocellular carcinomas (p = 0.803; p = 0.935).

CONCLUSION

Laparoscopic liver resections have identical long-term outcomes with lower overall morbidity. Laparoscopic liver resections offer advantages regarding transfusion rates, length of hospital stay and postoperative complications.

Performing laparoscopic surgery - Perspectives of young Chinese hepatobiliary surgeons

Laparoscopic liver resection (LLR) has garnered attention as a new form of liver surgery. In China, many hepatobiliary surgeons are now encouraging the examination and assessment of LLC in order to improve its outcomes, and several young hepatobiliary surgeons recently shared their clinical experiences and the results of their research in presentations at the Akamon Forum as part of the 118th Annual Congress of the Japan Surgical Society, which was held April 5-7, 2018 in Tokyo, Japan. In China, LLR has gradually improved over the past 20 years, including both expanded indications and improved surgical approaches. However, China is a vast country, and the level of medical care varies nationwide. Medical facilities that can perform advanced laparoscopic techniques are currently limited to those in large cities. Moreover, additional clinical studies of the long-term oncological outcomes of LLR need to be performed in the future.

Advancement in liver laparoscopic resection - development of a new surgical device

Liver resection is the standard treatment for any liver lesion. Laparoscopic liver resection is associated with lower intra-operative blood loss and fewer complications than open resection. Access to the posterior part of the right liver lobe is very uncomfortable and difficult for surgeons due the anatomic position, especially when employing laparoscopic surgery. Based on these experiences, a new laparoscopic device was developed that is capable of bending its long axis and allowing the application of radiofrequency energy in areas that were not technically accessible. The device is equipped with four telescopic needle electrodes that cause tissue coagulation after the delivery of radiofrequency energy. Ex vivo testing was performed in 2012 and 2014 at the University Hospital, Ostrava, on a porcine liver tissue. The main goal of this testing was to verify if the newly proposed electrode layout was suitable for sufficient tissue coagulation and creating a safety zone around lesions. During the ex vivo testing, the material of needle electrodes was improved to achieve the lowest possibility of adhesion. The power supply was adjusted from 20 to 120 W and the ablation time, which varied from 10 to 110 s, was monitored. Subsequently, optimal power delivery and time for coagulation was determined. This experimental study demonstrated the feasibility and safety of the newly developed device. Based on the ex vivo testing, LARA-K1 can create a safety zone of coagulation. For further assessment of the new device, an in vivo study should be performed.

Short-term outcomes of open liver resection and laparoscopic liver resection: Secondary analysis of data from a multicenter prospective study (CSGO-HBP-004)

The aim of the present study was to compare short-term outcomes of laparoscopic and open liver resection (LLR and OLR, respectively), and we first analyzed a preoperatively enrolled and prospectively collected database. We carried out a secondary analysis using a preoperative enrolled database that included the details of 786 patients who had been enrolled in a previously carried out randomized controlled trial to assess short-term outcomes, including morbidities. Statistical analyses included logistic regression, propensity score matching (PSM) with replacement, and inverse probability of treatment weighting (IPTW) analyses. Among 780 liver resections, OLR was carried out in 543 patients and LLR was carried out in 237 patients. LLR was selected in patients with a worse liver function and was related to a smaller resected liver weight and/or partial resection. Logistic regression, PSM, and IPTW analyses revealed that LLR was associated with less blood loss and a lower incidence of morbidities, but a longer operating time. LLR was found to be a preferred factor in biliary leakage by IPTW only. LLR was a preferred factor for blood loss, morbidities and hospital stay, but was associated with a longer operating time. UMIN-CTR, UMIN000003324.

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.

Cost-Effective Surgical Management of Liver Disease Amidst a Financial Crisis

BACKGROUND

Intraoperative use of specialized equipment and disposables contributes to the increasing cost of modern liver surgery. As a response to the recent severe financial crisis in our country we have employed a highly standardized protocol of liver resection that minimizes intraoperative and postoperative costs. Our goal is to evaluate cost-effectiveness of this protocol.

STUDY DESIGN

We evaluated retrospectively all patients who underwent open hepatic resections for 4 years. All resections were performed by the same surgical team under selective hepatic vascular exclusion, i.e., occlusion of the hepatoduodenal ligament and the major hepatic veins, occasionally combined with extrahepatic ligation of the ipsilateral portal vein. Sharp parenchymal transection was performed with a scalpel and hemostasis was achieved with sutures without the use of energy devices. In each case we performed a detailed analysis of costs and surgical outcomes.

RESULTS

Our cohort included 146 patients (median age 63 years). 113 patients were operated for primary or metastatic malignancies and 33 for benign lesions. Operating time was 121 ± 21 min (mean ± SD), estimated blood loss was 310 ± 159 ml (mean ± SD), and hospital stay was 7 ± 5 days (mean ± SD). Six patients required admission in the ICU postoperatively. 90-day mortality was 2.74 %, and 8.9 % of patients developed grade III/IV postoperative complications (Clavien-Dindo classification). Total in-hospital cost excluding physician fees was 6987.63 ± 3838.51 USD (mean ± SD).

CONCLUSIONS

Our analysis suggests that, under pressing economic conditions, the proposed surgical protocol can significantly lessen the financial burden of liver surgery without compromising patient outcomes.

Pure Laparoscopic Liver Resection for Malignant Liver Tumor: Anatomic Resection Versus Nonanatomic Resection

Background:

Laparoscopic liver resection (LLR) has been considered to be safe and feasible. However, few studies focused on the comparison between the anatomic and nonanatomic LLR. Therefore, the purpose of this study was to compare the perioperative factors and outcomes of the anatomic and nonanatomic LLR, especially the area of liver parenchymal transection and blood loss per unit area.

Methods:

In this study, surgical and oncological data of patients underwent pure LLR procedures for malignant liver tumor were prospectively collected. Blood loss per unit area of liver parenchymal transection was measured and considered as an important parameter. All procedures were conducted by a single surgeon.

Results:

During nearly 5 years, 84 patients with malignant liver tumor received a pure LLR procedure were included. Among them, 34 patients received anatomic LLR and 50 received nonanatomic LLR, respectively. Patients of the two groups were similar in terms of demographic features and tumor characteristics, despite the tumor size was significantly larger in the anatomic LLR group than that in the nonanatomic LLR group (4.77 ± 2.57 vs. 2.87 ± 2.10 cm, P = 0.001). Patients who underwent anatomic resection had longer operation time (364.09 ± 131.22 vs. 252.00 ± 135.21 min, P < 0.001) but less blood loss per unit area (7.85 ± 7.17 vs. 14.17 ± 10.43 ml/cm², P = 0.018). Nonanatomic LLR was associated with more blood loss when the area of parenchymal transection was equal to the anatomic LLR. No mortality occurred during the hospital stay and 30 days after the operation. Moreover, there was no difference in the incidence of postoperative complications. The disease-free and overall survival rates showed no significant differences between the anatomic LLR and nonanatomic LLR groups.

Conclusions:

Both anatomic and nonanatomic pure LLR are safe and feasible. Measuring the area of parenchymal transection is a simple and effective method to estimate the outcomes of the liver resection surgery. Blood loss per unit area is an important parameter which is comparable between the anatomic LLR and nonanatomic LLR groups.

Evaluating the current surgical strategies for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related death worldwide. Despite careful surveillance programs and the development of antiviral therapy for hepatitis virus infection, the occurrence rate of HCC remains high. Liver resection and liver transplantation are mainstay curative treatments. Most patients with HCC have impaired liver function, and surgical treatment is always accompanied by the risk of decompensation of the remnant liver, especially when the volume of the remnant liver is too small and the liver function too low to meet metabolic demands. The mortality of liver resection has dramatically decreased over the last three decades from 20% to less than 5% due to the accumulation of knowledge of liver anatomy, perioperative management and preoperative assessment of liver function. Here we provide an overview of the multidisciplinary treatments and current standard treatment strategies for HCC, to explore the possibility of expanding surgical treatments beyond the current standards.

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.

Comparison of laparoscopic liver resection for hepatocellular carcinoma located in the posterosuperior segments or anterolateral segments: A case-matched analysis

BACKGROUND

Laparoscopic liver resection is an attractive option for treating liver tumors. Laparoscopic liver resection is more difficult for hepatocellular carcinomas located in the posterosuperior segments than for hepatocellular carcinomas in the anterolateral segments. We compared perioperative and long-term outcomes between laparoscopic liver resection for hepatocellular carcinomas located in the posterosuperior and anterolateral segments.

METHODS

We retrospectively reviewed the clinical data for 230 patients who underwent laparoscopic liver resection for hepatocellular carcinomas between September 2003 and July 2014. Of these, 116 patients were selected by case-matched analysis using age, sex, tumor number and size, Child-Pugh class, and extent of liver resection. Patients were classified into 2 groups according to tumor location: the anterolateral group (n = 58) and the posterosuperior group (n = 58).

RESULTS

Operation time (355 minutes vs 212 minutes, P < .005), intraoperative blood loss (600 mL vs 410 mL, P < .001), and hospital stay (8.5 days vs 7 days, P = .040) were significantly greater in the posterosuperior group than in the anterolateral group. The open conversion (13.8% vs 10.3%, P = .777), postoperative complication (17.2% vs 10.3%, P = .420), 5-year overall survival (88.5% vs 85.7%, P = .370), and 5-year, recurrence-free survival (47.6% vs 40.9%, P = .678) rates were not significantly different between the posterosuperior and anterolateral groups.

CONCLUSION

Although laparoscopic liver resection is more difficult for hepatocellular carcinomas located in the posterosuperior segment, there were no differences in the short- and long-term outcomes between the posterosuperior and anterolateral groups. The perceived impact of tumor location on patient outcomes could be overcome by experience and technical improvements.