Laparoscopic liver re-resection is feasible for patients with posthepatectomy hepatocellular carcinoma recurrence: a propensity score matching study

Repeat laparoscopic hepatectomy versus radiofrequency ablation for recurrent hepatocellular carcinoma: A multicenter, propensity score matching analysis

This study aimed at analyzing and comparing the clinical efficacy and prognosis of repeat laparoscopic hepatectomy (r-LH) and radiofrequency ablation (RFA) in treating recurrent hepatocellular carcinoma (RHCC). Clinicopathological data of RHCC patients who underwent r-LH or RFA as treatment from three medical centers were retrospectively reviewed. Baseline characteristics at the recurrence time after initial hepatectomy and clinical outcomes following treatment of RHCC were compared between the two groups. Using the Kaplan-Meier method, survival curves for the two groups of patients were generated, and the log-rank test was used to compare survival differences. Propensity score matching (PSM) analysis was used to match patients of the r-LH and RFA groups in a 1:1 ratio. A total of 272 patients were enrolled, including 133 patients who underwent r-LH and 139 patients who received RFA. After PSM, 76 patients were matched in each study group. Compared with the r-LH group, the RFA group had shorter hospitalization and fewer postoperative complications. However, the r-LH group had significantly better overall survival (OS) and disease-free survival (DFS) than the RFA group before and after PSM. Subgroup analysis demonstrated that RHCC patients with solitary tumor or those with tumors located near the diaphragm, visceral surface or vessels, had survival benefits from r-LH. When tumor diameter ≤ 5 cm, r-LH appears to be an effective priority to RFA with a significantly higher OS and DFS rate in treating RHCC patients, especially for patients with solitary tumor and those with tumors located near the diaphragm, visceral surface or vessels.

Robotic versus laparoscopic repeat hepatectomy: A comparative single-center study of perioperative outcomes

PURPOSE

A repeat liver resection is considered a technically challenging procedure and therefor an open approach is frequently preferred. With the introduction of minimally invasive liver surgery, laparoscopic repeat liver resection demonstrates favorable results, however, limited data on robotic repeat liver resections exists. Our aim is to compare the robotic approach with the laparoscopic one for a repeat liver resection.

METHODS

In a single-center retrospective analysis, we report the data of all minimally invasive repeat liver resections performed between September 2011 and August 2023. Short-term outcomes - including procedure time, blood loss, conversion rate, morbidity and mortality - were compared for a laparoscopic and a robotic approach.

RESULTS

A total of 136 minimally invasive repeat liver resections were performed, of which 56 robotic procedures and 80 laparoscopic procedures. Both groups were similar in baseline demographics, diagnosis and surgical procedure. While the mean procedure time was slightly longer in the robotics group by 15 min (145min and 130min, p = 0.04), the median blood loss was significantly lower in the robotic group (30 ml and 80 ml, p < 0.001). Additionally, there was a trend towards less conversions in the robotic group (n = 0 and n = 6, p = 0.42). Post-operative morbidity and mortality were similar in both groups.

CONCLUSION

The robotic approach for minimally invasive repeat liver surgery is both safe and feasible, while also demonstrating favorable short-term outcomes. In our experience, the 'tunnel technique' - which avoids dissection of intra-abdominal adhesions - is a key advantage of this approach.

Reappraisal of safety and oncological outcomes of laparoscopic repeat hepatectomy in patients with recurrent hepatocellular carcinoma: it is feasible for the pioneer surgical team

BACKGROUND

Hepatocellular carcinoma (HCC) is prevalent in Taiwan, primarily due to the high incidence of hepatitis B and C infections, with high recurrence rates of 50-70% within five years after initial treatment. Treatment options for recurrent HCC include salvage liver transplantation, trans-arterial chemoembolization, re-hepatectomy, and radiofrequency ablation. Repeat hepatectomy exhibits superior oncological outcomes compared with alternative approaches. Although laparoscopic liver resection has demonstrated safety and feasibility for primary HCC resection, the persistence of intrahepatic recurrence necessitates effective intervention. However, repeat liver resection poses several challenges including adhesions from previous surgeries, limited access to recurrent tumors, altered liver structure post-regeneration, difficulties in obtaining hilar control, and compromised liver reserves. Suggesting a laparoscopic approach for recurrent HCC is typically based on the surgeons' experience and confidence. In this study, we reconfirmed the safety, feasibility and oncological outcome of laparoscopic repeat liver resection and investigated the optimal timing for initiation of this procedure by a pioneering team in minimally invasive liver resection.

METHODS

We retrospectively reviewed our collective experience of 57 patients with recurrent HCC between January 2009 and December 2021.The patients were followed until June 30, 2024. Among them, 37 underwent laparoscopic approaches and 20 opted for open procedures.

RESULTS

Both groups exhibited similar operative times and perioperative outcomes, with significantly reduced hospital stays in the laparoscopic cohort (median: 5 vs. 7, p < 0.001). The median follow-up duration was 41.5 months (range, 2.8 to 112.6 months). Mortality occurred in 22 patients (38.6%) and recurrence occurred in 26 patients (45.6%) The overall survival and disease-free survival after the operation were similar in both groups and comparative to the literatures.

CONCLUSION

Using a stepwise approach, laparoscopic repeat liver resection can be performed safely and effectively with a low incidence of conversion by an experienced surgical team with similar oncological outcomes. The introduction of laparoscopic techniques has also sparked a strategic shift in the surgical approach for recurrent HCC. This treatment option should be offered to patients by an experienced surgical team for minimally invasive liver resections.

Robotic or laparoscopic repeat hepatectomy after open hepatectomy: a cohort study

BACKGROUND

Repeat hepatectomies are technically complex procedures. The evidence of robotic or laparoscopic (= minimally invasive) repeat hepatectomies (MIRH) after previous open hepatectomy is poor. Therefore, we compared postoperative outcomes of MIRH vs open repeat hepatectomies (ORH) in patients with liver tumors after previous open liver resections.

METHODS

Consecutive patients who underwent repeat hepatectomies after open liver resections were identified from a prospective database between April 2018 and May 2023. Postoperative complications were graded in line with the Clavien-Dindo classification. We stratified patients by intention to treat into MIRH or ORH and compared outcomes. Logistic regression analysis was performed to define variables associated with the utilization of a minimally invasive approach.

RESULTS

Among 46 patients included, 20 (43%) underwent MIRH and 26 (57%) ORH. Twenty-seven patients had advanced or expert repeat hepatectomies (59%) according to the IWATE criteria. Baseline characteristics were comparable between the study groups. The use of a minimally invasive approach was not dependent on preoperative or intraoperative variables. All patients had negative resection margins on final histology. MIRH was associated with less blood loss (450 ml, IQR (interquartile range): 200-600 vs 600 ml, IQR: 400-1500 ml, P = 0.032), and shorter length of stay (5 days, IQR: 4-7 vs 7 days, IQR: 5-9 days, P = 0.041). Postoperative complications were similar between the groups (P = 0.298).

CONCLUSIONS

MIRH is feasible after previous open hepatectomy and a safe alternative approach to ORH. (German Clinical Trials Register ID: DRKS00032183).

Radiofrequency ablation for pediatric recurrent hepatocellular carcinoma: a single-center experience

PURPOSE

To summarize our single-center experience with percutaneous ultrasound (US)-guided radiofrequency ablation (RFA) for pediatric recurrent hepatocellular carcinoma (RHCC).

METHODS

From September 2007 to September 2021, patients under 18 who underwent percutaneous US-guided RFA for RHCC were retrospectively enrolled in this study. Local effectiveness, complications, local tumor progression (LTP), progression free survival (PFS), and overall survival (OS) were evaluated.

RESULTS

A total of 10 patients (9 male and 1 female; mean age, 11.7 ± 4 years ; age range, 6-17 years) with 15 intrahepatic RHCC lesions were enrolled in this study. Complete ablation (CA) was achieved in 14 out of 15 lesions (93.3%) after the first RFA. During the follow-up (mean, 63.1 ± 18 months; range, 5.3-123.3 months), LTP did not occur. Five patients died including three with tumor progression and one with liver failure. The accumulative one- and three-year PFS rates were 30% and 10%, respectively. The accumulative one- and three-year OS rates were 77.8% and 44.4%, respectively.

CONCLUSIONS

Our single-center experience suggests the safety and feasibility of percutaneous US-guided RFA for pediatric RHCC.

Surgical site wound infection and pain after laparoscopic repeat hepatectomy for recurrent hepatocellular carcinoma

This study aimed to compare the effects of laparoscopic repeat liver resection (LRLR) and open repeat liver resection (ORLR) on surgical site wound infection and pain in recurrent hepatocellular carcinoma. PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure, and Wanfang Data were systematically searched for studies comparing LRLR with ORLR for the treatment of recurrent hepatocellular carcinoma, with a search timeframe from their inception to December 2022. Two investigators independently screened the literature, extracted information, and evaluated the quality of the studies according to the inclusion and exclusion criteria. This study was performed using RevMan 5.4 software. A total of 20 publications with 4380 patients were included, with 1108 and 3289 patients in the LRLR and ORLR groups, respectively. The results showed that LRLR significantly reduced surgical site wound infection rate (1.71% vs. 5.16%, odds ratio [OR]:0.32, 95% confidence interval [CI]: 0.18-0.56, P < .001), superficial wound infection rate (1.29% vs. 4.92%, OR: 0.29, 95% CI: 0.14-0.58, P < .001), bile leakage (3.34% vs. 6.05%, OR: 0.59, 95% CI: 0.39-0.90, P = .01), organ/space wound infection rate (0.4% vs. 5.11%, OR: 0.23, 95% CI: 0.07-0.81, P = .02), and surgical site wound pain (mean difference: -2.00, 95% CI: -2.99 to -1.02, P < .001). Thus, the findings of this study showed that LRLR for recurrent hepatocellular carcinoma significantly reduced wound infection rates and improved postoperative wound pain.

Advantages of the Laparoscopic Approach for the Initial Operation in Patients who Underwent Repeat Hepatectomy

BACKGROUND

Less intra-abdominal adhesions are expected following laparoscopic surgery. Although an initial laparoscopic approach for primary liver tumors may have advantages in patients who require repeat hepatectomies for recurrent liver tumors, this has not been sufficiently investigated.

METHODS

Patients who underwent repeat hepatectomies for recurrent liver tumors at our hospital between 2010 and 2022 were retrospectively analyzed. Of 127 patients, 76 underwent laparoscopic repeat hepatectomy (LRH), of whom 34 patients initially underwent laparoscopic hepatectomy (L-LRH) and 42, open hepatectomy (O-LRH). Fifty-one patients underwent open hepatectomy as both the initial and second operation (O-ORH). We analyzed surgical outcomes between L-LRH and O-LRH groups and between L-LRH and O-ORH groups using propensity-matching analysis for each pattern.

RESULTS

Twenty-one patients each were included in L-LRH and O-LRH propensity-matched cohorts. The L-LRH group had a lower rate of postoperative complications than the O-LRH group (0 vs 19%, P = 0.036). When we compared surgical outcomes between L-LRH and O-ORH groups in another matched cohort with 18 patients in each group, in addition to the lower rate of postoperative complications, the L-LRH group had additional favorable surgical outcomes including shorter operation time and lower blood loss volume than the O-ORH group (291 vs 368 min, P = 0.037 and 10 vs 485 mL, P < 0.0001).

CONCLUSIONS

An initial laparoscopic approach would be favorable for patients undergoing repeat hepatectomies, as it leads to lower risk of postoperative complications. Compared with O-ORH, the advantage of the laparoscopic approach may be enhanced when it is repeatedly adopted.

Laparoscopic versus open repeat hepatectomy for recurrent hepatocellular carcinoma: a systematic review and meta-analysis of propensity score-matched cohort studies

OBJECTIVE

The effectiveness of laparoscopic repeat hepatectomy (LRH) versus open repeat hepatectomy (ORH) on recurrent hepatocellular carcinoma (RHCC) is unclear. We compared the surgical and oncological outcomes of LRH and ORH in patients with RHCC with a meta-analysis of studies based on propensity score-matched cohorts.

METHODS

A literature search was conducted on PubMed, Embase, and Cochrane Library with Medical Subject Headings terms and keywords until 30 September 2022. The quality of eligible studies was evaluated with the Newcastle-Ottawa Scale. Mean difference (MD) with a 95% CI was used for the analysis of continuous variables; odds ratio (OR) with 95% CI was used for binary variables; and hazard ratio with 95% CI was used for survival analysis. A random-effects model was used for meta-analysis.

RESULTS

Five high-quality retrospective studies with 818 patients were included; 409 patients (50%) were treated with LRH and 409 (50%) with ORH. In most surgical outcomes, LRH was superior to ORH: less estimated blood loss, shorter operation time, lower major complication rate, and shorter length of hospital stay (MD=-225.9, 95% CI=[-360.8 to -91.06], P =0.001; MD=66.2, 95% CI=[5.28-127.1], P =0.03; OR=0.18, 95% CI=[0.05-0.57], P =0.004; MD=-6.22, 95% CI=[-9.78 to -2.67], P =0.0006). There were no significant differences in the remaining surgical outcomes: blood transfusion rate and overall complication rate. In oncological outcomes, LRH and ORH were not significantly different in 1-year, 3-year, and 5-year overall survival and disease-free survival.

CONCLUSIONS

For patients with RHCC, most surgical outcomes with LRH were superior to those of ORH, but oncological outcomes with the two operations were similar. LRH may be a preferable option for the treatment of RHCC.

Current status and prospect of treatments for recurrent hepatocellular carcinoma

Owing to its heterogeneous and highly aggressive nature, hepatocellular carcinoma (HCC) has a high recurrence rate, which is a non-negligible problem despite the increasing number of available treatment options. Recent clinical trials have attempted to reduce the recurrence and develop innovative treatment options for patients with recurrent HCC. In the event of liver remnant recurrence, the currently available treatment options include repeat hepatectomy, salvage liver transplantation, tumor ablation, transcatheter arterial chemoembolization, stereotactic body radiotherapy, systemic therapies, and combination therapy. In this review, we summarize the strategies to reduce the recurrence of high-risk tumors and aggressive therapies for recurrent HCC. Additionally, we discuss methods to prevent HCC recurrence and prognostic models constructed based on predictors of recurrence to develop an appropriate surveillance program.

Challenging Scenarios and Debated Indications for Laparoscopic Liver Resections for Hepatocellular Carcinoma

Laparoscopic liver resections (LLRs) have been increasingly adopted for the treatment of hepatocellular carcinoma (HCC), with safe short- and long-term outcomes reported worldwide. Despite this, lesions in the posterosuperior segments, large and recurrent tumors, portal hypertension, and advanced cirrhosis currently represent challenging scenarios in which the safety and efficacy of the laparoscopic approach are still controversial. In this systematic review, we pooled the available evidence on the short-term outcomes of LLRs for HCC in challenging clinical scenarios. All randomized and non-randomized studies reporting LLRs for HCC in the above-mentioned settings were included. The literature search was run in the Scopus, WoS, and Pubmed databases. Case reports, reviews, meta-analyses, studies including fewer than 10 patients, non-English language studies, and studies analyzing histology other than HCC were excluded. From 566 articles, 36 studies dated between 2006 and 2022 fulfilled the selection criteria and were included in the analysis. A total of 1859 patients were included, of whom 156 had advanced cirrhosis, 194 had portal hypertension, 436 had large HCCs, 477 had lesions located in the posterosuperior segments, and 596 had recurrent HCCs. Overall, the conversion rate ranged between 4.6% and 15.5%. Mortality and morbidity ranged between 0.0% and 5.1%, and 18.6% and 34.6%, respectively. Full results according to subgroups are described in the study. Advanced cirrhosis and portal hypertension, large and recurrent tumors, and lesions located in the posterosuperior segments are challenging clinical scenarios that should be carefully approached by laparoscopy. Safe short-term outcomes can be achieved provided experienced surgeons and high-volume centers.

Surgical Strategies for Recurrent Hepatocellular Carcinoma after Resection: A Review of Current Evidence

Hepatocellular carcinoma (HCC) is the most common primary liver cancer, and both liver resection and liver transplantation are considered potentially curative options. However, high recurrence rates affect the prognosis depending both on the primary HCC pathology characteristics or on the type and time of the relapse. While great attention has been usually posted on treatment algorithms for the first HCC, treatment algorithms for recurrent HCC (rHCC) are lacking. In these cases, surgery still represents a curative option with both redo hepatectomy and/or salvage liver transplantation, which are considered valid treatments in selected patients. In the current era of personalised medicine with promises of new systemic-targeted immuno-chemotherapies, we wished to perform a narrative review of the literature on the role of surgical strategies for rHCC.

The role of laparoscopic surgery in the surgical management of recurrent liver malignancies: A systematic review and meta-analysis

Objective

To evaluate the efficiency of laparoscopic surgery in treating recurrent liver tumors vs. conventional open surgery.

Methods

Database searching was conducted in PubMed, the Cochrane Library and EMBASE. Rev Man 5.3 software and Stata 13.0 software were applied in statistical analyses.

Results

A total of fourteen studies were finally included with 1,284 patients receiving LRH and 2,254 with ORH. LRH was associated with less intraoperative hemorrhage, a higher R0 resection rate, a lower incidence of Pringle Maneuver, a lower incidence of postoperative morbidities, a better overall survival and an enhanced postoperative recovery vs. ORH. Patients receiving LRH shared similar operative time, tumor number and disease-free survival as those with ORH. However, tumor size was relatively larger in patients receiving ORH and major hepatectomy, anatomic hepatectomy were rarely performed in patients with LRH. Additional analyses between LRH and laparoscopic primary hepatectomy revealed less intraoperative blood loss in patients with LRH.

Conclusion

LRH is safe and feasible with more favorable peri-operative outcomes and faster postoperative recovery. However, it is only applicable for some highly-selected cases not requiring complex surgical procedures. Future larger well-designed studies are expected for further validation.

Perioperative and short-term outcomes of laparoscopic liver resection for recurrent hepatocellular carcinoma: A retrospective study comparing open hepatectomy

Background

To compare the perioperative and short-term outcomes of laparoscopic liver resection (LLR) and open liver resection (OLR) in recurrent hepatocellular carcinoma (rHCC) based on propensity score matching (PSM) to investigate therapeutic safety, efficacy, and value for clinical application.

Methods

Forty-nine patients with rHCC who underwent surgery at Wenzhou People’s Hospital between January 2017 and March 2022 were retrospectively analyzed and classified into LLR (n=30) and OLR (n=22) cases based on the surgical method. Thirty-eight patients were screened using PSM for data analysis to compare basic clinical characteristics, perioperative outcomes, and postoperative recurrence in both groups.

Results

Before PSM, the tumour diameter was larger, tumor staging (BCLC staging system), intraoperative blood loss, units of blood transfused, constituent ratio of liver cirrhosis, incidence of MVI and intravascular tumour thrombus and postoperative complication were higher, and duration of hospital stay was significantly longer in the OLR group compared to those in the LLR group (p &lt; 0.05). After PSM, there were no significant differences regarding tumour diameter, MVI incidence, blood transfusion amount or postoperative complication rate in the LLR and OLR groups. The tumor staging, incidence of vascular cancer thrombus, intraoperative blood loss and postoperative duration of hospitalisation were significantly higher in the OLR group than in the LLR group (p&lt;0.05). The difference in recurrence-free survival (RFS) between the two groups was not statistically significant (p = 0.383).

Conclusion

LLR for recurrent hepatocellular carcinoma can reduce intraoperative blood loss and postoperative complication rate, shorten the duration of hospitalisation, and is superior to OLR regarding perioperative and short-term efficacy, demonstrating good safety and feasibility.

Laparoscopic repeat hepatectomy versus conventional open repeat hepatectomy for recurrent hepatocellular carcinoma: A systematic review and meta-analysis

BACKGROUND

Repeat hepatectomy has been proven to be an effective treatment in patients with recurrent hepatocellular carcinoma (RHCC). However, for RHCC, it is still controversial whether laparoscopic hepatectomy is superior to conventional ones. The present meta-analysis was carried out to investigate the safety and overall effect of laparoscopic repeat hepatectomy (LRH) to open repeat hepatectomy (ORH) for patients with RHCC.

METHODS

A meta-analysis was registered at PROSPERO, and the registration number is CRD42021257569. PubMed, Web of Science, and EMBASE were searched based on a defined search strategy to identify eligible studies before 25 April 2022. Data on operative times, bleeding volume, overall complications, 90-day mortality, blood transfusion, length of stay, overall survival rate, and long-term recurrence-free survival rate were subjected to meta-analysis.

RESULTS

Overall, we identified nine studies of LRH versus ORH enrolling a total of 945 patients (460 and 485 underwent LRH and ORH, respectively). The present meta-analysis revealed non-significant differences in operative time, blood transfusion, overall complications, 90-day mortality, 3-year overall survival rate, 5-year overall survival rate, and long-term recurrence-free survival rate between the two groups. Alternatively, comparing LRH with ORH, LRH has less bleeding volume (p < 0.001) and a shorter length of stay (p = 0.005).

CONCLUSION

LRH is a feasible and effective treatment strategy for RHCC.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/PROSPERO/#searchadvanced, identifier CRD42021257569.

Efficacy of laparoscopic repeat hepatectomy compared with open repeat hepatectomy: a single-center, propensity score matching study

Introduction

Laparoscopic repeat hepatectomy (LRH) is considered to be a technically challenging procedure which has not been widely applied. This study aimed to assess the accessibility and security of LRH for patients with hepatic tumor recurrence.

Methods

Between January 2010 and October 2020, we performed 48 LRHs and 31 open repeat hepatectomies (ORHs) for recurrent liver cancer. LRHs were matched to ORHs (1:1) using propensity score matching (PSM) created by comparing preoperative factors. The perioperative data of patients were retrospectively analyzed, including baseline data, operative time, intraoperative blood loss, pathology, days of postoperative stay, complication morbidity, and mortality within 30 days. Overall survival and recurrence-free survival rates with appropriate follow-up were obtained to evaluate the long-term outcomes.

Results

Compared with the ORH, LRH was related with shorter operative duration (169.9 versus 232.9 ml, p < 0.01), less intraoperative bleeding (100.0 versus 500.0 ml, p < 0.01), lower rate of blood transfusion (8.3% versus 58.1%, p < 0.01), and shorter hospitalization (5.0 versus 11.0 days, p < 0.01). The median follow-up was 31 months. The LRH 1-, 3-, and 5-year overall survival were 77.1%, 61.6%, and 46.2% versus 82.3%, 66.5%, and 29.5% for ORH (p = 0.77). The 1-, 3-, and 5-year disease-free survival rates of the two groups were 73.4%, 62.0%, and 44.3% versus 66.1%, 44.1%, and 14.7%, respectively (p = 0.22).

Conclusions

Laparoscopic repeated hepatectomy is safe and practicable with great short-term results for selected patients.

Laparoscopic vs open liver re-resection for cirrhotic patients with post-hepatectomy hepatocellular carcinoma recurrence: A comparative study

BACKGROUND

Repeated liver resection is an effective treatment for recurrent hepatocellular carcinoma (HCC). However, few studies have compared the outcome of laparoscopic repeat hepatectomy (LRH) and open repeat hepatectomy (ORH) for recurrent HCC, and few of those have included cirrhotic patients.

AIM

To compare short-term and long-term outcomes of cirrhotic patients with LRH and ORH for recurrent HCC.

METHODS

We retrospectively analysed the clinical records retrieved from a prospectively collected database of all patients who underwent hepatectomy for post-hepatectomy recurrent HCC at our institute between May 2006 and June 2021. Cases of recurrent HCCs larger than 7 cm were excluded. Patient demographics, operative details, perioperative outcomes, pathologic details, disease-free survival (DFS), and overall survival (OS) data of LRH and ORH were compared.

RESULTS

Data from 29 patients with LRH and 22 with ORH were compared. The LRH group showed significantly better outcomes for blood loss (median 300 mL vs 750 mL, P = 0.013) and length of hospital stay (median 5 d vs 7 d, P = 0.003). The 1-, 3- and 5-year OS rates in the LRH group were 100.0%, 60.0% and 30.0%, respectively; the corresponding rates in the ORH group were 81.8%, 36.4% and 18.2% (P = 0.336). The 1-, 3- and 5-year DFS rates in the LRH group were 68.2%, 27.3% and 4.5%, respectively; the corresponding rates in the ORH group were 31.3%, 6.3% and 6.3% (P = 0.055). There were no significant differences in overall and DFS between the two groups.

CONCLUSION

Laparoscopic re-resection should be considered for patients presenting with recurrent HCC less than or equal to 7 cm after previous hepatectomy.

The role of re-resection in recurrent hepatocellular carcinoma

Purpose

While liver resection is a well-established treatment for primary HCC, surgical treatment for recurrent HCC (rHCC) remains the topic of an ongoing debate. Thus, we investigated perioperative and long-term outcome in patients undergoing re-resection for rHCC in comparative analysis to patients with primary HCC treated by resection.

Methods

A monocentric cohort of 212 patients undergoing curative-intent liver resection for HCC between 2010 and 2020 in a large German hepatobiliary center were eligible for analysis. Patients with primary HCC (n = 189) were compared to individuals with rHCC (n = 23) regarding perioperative results by statistical group comparisons and oncological outcome using Kaplan–Meier analysis.

Results

Comparative analysis showed no statistical difference between the resection and re-resection group in terms of age (p = 0.204), gender (p = 0.180), ASA category (p = 0.346) as well as main preoperative tumor characteristics, liver function parameters, operative variables, and postoperative complications (p = 0.851). The perioperative morbidity (Clavien-Dindo ≥ 3a) and mortality were 21.7% (5/23) and 8.7% (2/23) in rHCC, while 25.4% (48/189) and 5.8% (11/189) in primary HCC, respectively (p = 0.851). The median overall survival (OS) and recurrence-free survival (RFS) in the resection group were 40 months and 26 months, while median OS and RFS were 41 months and 29 months in the re-resection group, respectively (p = 0.933; p = 0.607; log rank).

Conclusion

Re-resection is technically feasible and safe in patients with rHCC. Further, comparative analysis displayed similar oncological outcome in patients with primary and rHCC treated by liver resection. Re-resection should therefore be considered in European patients diagnosed with rHCC.

Laparoscopic versus open repeat liver resection for recurrent hepatocellular carcinoma in hepatectomy patients: inverse probability of treatment weighting

Repeat liver resection (RLR) is a good treatment option for recurrent hepatocellular carcinoma (HCC). However, laparoscopic repeat liver resection (LRLR) is more technically demanding than open repeat liver resection (ORLR). The purpose of our study is to compare the surgical outcomes of ORLR and LRLR and to carefully present LRLR guidelines for HCC. We performed RLR at a single institution from January 2017 to November 2019. We divided the patients into an ORLR group and an LRLR group. Inverse probability of treatment weighting (IPTW) was applied in this study to compare the ORLR group and the LRLR group. There was no difference between the two groups in patient characteristics, preoperative blood tests and pathological characteristics. After stabilized IPTW, the LRLR group had a shorter hospital stay (5.52 vs. 9.27 days, p = 0.001) and superior disease-free survival (p = 0.020). LRLR yielded better short-term outcomes than ORLR. And if a regular radiologic examination is performed, most of the recurrent tumors could be detected less than 3 cm. In conclusion, LRLR might be feasible and useful for recurrent HCC located contralateral to the previous tumor at a size of less than 3 cm.

Is minimally invasive liver surgery a reasonable option in recurrent HCC? A snapshot from the I Go MILS registry

Laparoscopic liver resection (LLR) for Hepatocellular carcinoma (HCC) is a safe procedure. Repeat surgery is more often required, and the role of minimally invasive liver surgery (MILS) is not yet clearly defined. The present study analyzes data compiled by the Italian Group of Minimally Invasive Liver Surgery (IGoMILS) on LLR. To compare repeated LLR with the first LLR for HCC is the primary endpoint. The secondary endpoint was to evaluate the outcome of repeat LLR in the case of primary open versus primary MILS surgery. The data cohort is divided into two groups. Group 1: first liver resection and Group 2: Repeat LLR. To compare the two groups a 3:1 Propensity Score Matching is performed to analyze open versus MILS primary resection. Fifty-two centers were involved in the present study, and 1054 patients were enrolled. 80 patients underwent to a repeat LLR. The type of resection was different, with more major resections in the group 1 before matching the two groups. After propensity score matching 3:1, each group consisted of 222 and 74 patients. No difference between the two groups was observed. In the subgroup analysis, in 44 patients the first resection was performed by an open approach. The other 36 patients were resected with a MILS approach. We found no difference between these two subgroups of patients. The present study in repeat MILS for HCC using the IGoMILS Registry has observed the feasibility and safety of the MILS procedure.

Indications of Laparoscopic Repeat Liver Resection for Recurrent Hepatocellular Carcinoma

AIM

This study aimed to evaluate the indications of laparoscopic repeat liver resection (LRLR) for recurrent hepatocellular carcinoma from the viewpoint of its difficulty.

METHODS

One hundred and one patients who underwent LRLR and 59 patients who underwent open repeat liver resection (ORLR) were included. The difficulty was classified according to the preoperative predictive factors for difficult LRLR, including an open approach during previous liver resection, history of two or more previous liver resections, history of previous major liver resection, tumor near the resected site of the previous liver resection, and intermediate or high difficulty with the difficulty scoring system. We compared the surgical outcomes between the LRLR and ORLR groups based on the difficulty class (low- or intermediate difficiulty class, 0 to 3 predictive factors; high difficiulty class, 4 or 5 factors).

RESULTS

In the low- or intermediate difficiulty class, intraoperative blood loss and the proportion of patients with postoperative complications were significantly lower in LRLR than in ORLR, and the duration of the postoperative hospital stay was significantly shorter in LRLR than in ORLR. In the high difficiulty class, total operative time and operative time before starting hepatic parenchymal resection were significantly longer in LRLR than in ORLR, and there were no significant differences in other surgical outcomes between the two groups.

CONCLUSION

LRLR is recommended for patients in the low or intermediate difficulty class. However, LRLR does not have an advantage with longer operative time for patients in the high difficulty class compared with ORLR.

Laparoscopic vs. Open Repeat Hepatectomy for Recurrent Liver Tumors: A Propensity Score-Matched Study and Meta-Analysis

Background: It remains unclear whether the short-term benefits of laparoscopic repeat hepatectomy (LRH) accrue to patients with recurrent liver tumors. The present study aimed to report our own center's experience and perform a meta-analysis to evaluate the safety and feasibility of LRH in comparison with open repeat hepatectomy (ORH) for treating recurrent liver tumors.

Patients and Methods: A propensity score–matched study was performed including 426 patients receiving LRH or ORH for recurrent hepatocellular carcinoma between January 2017 and December 2018. Surgical outcomes and perioperative inflammation-based markers, including monocyte-to-lymphocyte ratio, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and systemic immune–inflammation index were collected from medical records and analyzed. Additionally, a systematic literature review was performed to identify relevant studies in PubMed, EMBASE, Web of Science, and Cochrane library databases up to October 1, 2020. Information including patient demographics, pathologic characteristics, and short-term outcomes was extracted and analyzed using random- or fixed-effects models.

Results: Of 68 LRHs, 57 were matched with an ORH finally. Our study demonstrated that LRH was significantly associated with less intraoperative blood loss (50 vs. 100 mL; P < 0.001), lower rate of hepatic inflow occlusion (10.52 vs. 33.3%; P = 0.003), and shorter postoperative hospital stay (5 vs. 6 days; P = 0.001) after 1:1 propensity score matching. The operation time, rate of blood transfusion, and postoperative complications were similar between the two groups. Moreover, all four inflammation-based markers were significantly lower in LRH group on postoperative day 1. In the meta-analysis, a total of 12 studies comprising 1,315 patients receiving repeat hepatectomy met the selection criteria. Similar to our own study, the meta-analysis showed shorter hospital stay [standard mean difference (SMD) = −0.51, 95% confidence interval (CI) = −0.79 to −0.22, P < 0.001], less intraoperative blood loss (SMD = −0.79, 95% CI = −1.11 to −0.47, P < 0.001), and lower rate of major postoperative complications [odds ratio (OR) = 0.35, 95% CI = 0.19–0.66, P = 0.001] in the LRH group. There was no difference in the field of overall postoperative complication and operation time between LRH and ORH groups.

Conclusion: Compared with ORH, LRH results in relatively better surgical outcomes and faster postoperative recovery. It could be considered a feasible and effective option for the treatment of recurrent liver tumors.

Comparison of surgical outcomes for laparoscopic liver resection of large hepatocellular carcinomas: A retrospective observation from single-center experience

BACKGROUND/PURPOSE

Although laparoscopic liver resection (LLR) is a common surgical procedure for hepatocellular carcinoma (HCC), its suitability for large HCCs (≥5 cm) remains controversial. This study compared surgical outcomes of open hepatectomy with LLR for large HCCs.

METHODS

A total of 313 patients with HCC who underwent hepatectomy between January 2010 and June 2017 were analyzed retrospectively. Demographic data, short-term outcomes, and long-term survivals were analyzed.

RESULTS

Among patients with large HCCs (n = 122), the open group (n = 85) had larger tumor sizes (10.91 ± 4.72 vs. 7.45 ± 2.95 cm; p < 0.001) and more advanced stages (stages 3/4: 71.8% vs. 45.9%; p = 0.029) than the LLR group (n = 37), while LLR group achieved less blood loss (623.24 ± 841.75 mL vs. 1091.76 ± 1004.72 mL, p = 0.014) and shorter LOS (9.00 ± 5.13 d vs. 12.82 ± 8.51 d, p = 0.013). There were no significant differences in complication and mortality rates between groups. The 5-year overall and recurrence-free survival rates between the two groups were not significantly different (p = 0.408 and 0.644 respectively). The surgical outcomes showed equal benefit of the two operation types.

CONCLUSION

With sufficient surgeon experience and appropriate patient selection, LLR is a feasible treatment choice for large HCCs.

Intrahepatic recurrence of hepatocellular carcinoma after resection: an update

Hepatocellular carcinoma recurrence occurs in 40-70% of patients after hepatic resection. Despite the high frequency of hepatocellular cancer relapse, there is no established guidance for the management of such cases. The evaluation of prognostic factors that indicate a high risk of recurrence after surgery such as the tumor number and size and the presence of microvascular invasion may guide the therapeutic strategy and point out which patients should be strictly monitored. Additionally, the administration of adjuvant treatment or ab initio liver transplantation in selected patients with high-risk characteristics could have a significant impact on the prevention of relapse and overall survival. Once the recurrence has occurred in the liver remnant, the available therapeutic options include re-resection, salvage liver transplantation and locoregional treatments, although the therapeutic choice is often challenging and should be based on the characteristics of the recurrent tumor, the patient profile and most importantly the timing of relapse. Aggressive combination treatments are often required in challenging cases of early relapse. The results of the above treatment strategies are reviewed and compared to determine the optimal management of patients with recurrent hepatocellular cancer following liver resection.

Laparoscopic repeat hepatectomy for treating recurrent liver cancer

Background

Laparoscopic repeat hepatectomy (LRH) is a technically challenging procedure, so LRH for recurrent liver cancer has not been widely accepted. The aim of this study was to perform a systematic review of the current literature to identify and evaluate available data of LRH for recurrent hepatocellular carcinoma (rHCC) and metastases tumour of liver, especially of colorectal liver metastases (CRLM), focusing on the safety and feasibility.

Methods

A comprehensive search of the PubMed database was performed for all studies published in English evaluating LRH for rHCC and recurrent metastases tumour of liver from 1^st January, 2005 to 1^st June, 2019.

Results

A total of 15 studies which comprised 444 patients and reported outcomes for the efficacy and safety of LRH in the treatment of rHCC or CRLM were included in the present review. Moreover, nine studies compared the perioperative outcomes of LRH versus open repeat hepatectomy (ORH). LRH was superior to ORH with reduced blood loss, shorter operative time, shorter hospital stay and lower morbidity rates.

Conclusions

LRH can safely performed in rHCC or CRLM patients with cirrhosis, previous open hepatectomy, multiple recurrent lesions and tumours located in difficult posterosuperior segments.

Analysis of perioperative outcomes following laparoscopic repeat liver resection compared to laparoscopic primary liver resection based on a single surgeon's experience: A 1:2 propensity score-matched study

BACKGROUND

We report a single surgeon experience with laparoscopic repeat liver resection (LRLR), and analyse short-term outcomes relative to laparoscopic primary liver resection (LPLR).

METHODS

Two-hundred and twenty-two laparoscopic liver resections were performed from 2012 to 2019 of which 33 were LRLR. 1:2 propensity-score matching was done to compare 32 LRLR with 64 LPLR cohort. We further analyzed the first 16 LRLR cases compared to the subsequent 17 cases.

RESULTS

32 LRLR cases were matched to 64 LPLR cases. Apart from a higher frequency of Pringle maneuver in the LPLR cohort (p = 0.006), there were no differences in other perioperative outcomes. There were more posterosuperior located tumours (75.0% vs 17.6%, p = 0.003) and higher median difficulty score (8.50 vs 5.00, p = 0.025) in the initial 16 LRLR cases compared to the next 17. The earlier group had higher median blood loss (250.00 ml vs 50.00 ml, p = 0.012), but other outcomes were similar.

CONCLUSION

LRLR may be safely performed in selected patients with no difference in key perioperative outcomes compared to LPLR.

Oridonin Sensitizes Hepatocellular Carcinoma to the Anticancer Effect of Sorafenib by Targeting the Akt Pathway

Background

Oridonin is the core bioactive component of Rabdosia rubescens, a traditional Chinese herbal medicine used in the treatment of hepatoma. Sorafenib, a targeted therapeutic agent for advanced hepatocellular carcinoma (HCC), has recently been shown to exert limited clinical effects. However, few studies have focused on the synergistic effect of these two drugs on hepatocellular carcinoma.

Methods

We treated different HCC cell lines with different concentrations of oridonin and sorafenib and assessed the viability by using MTT assays and examined proliferation, migration, invasion and apoptosis after cotreatment of HepG2 cells with 20 μM oridonin and 5 μM sorafenib via colony formation assays, Transwell assays and flow cytometry. Regulatory effects were measured by Western blotting. The in vivo synergistic effect was confirmed through xenograft tumor models, and tumor tissues were analyzed by immunohistochemistry.

Results

The inhibitory effects of oridonin and sorafenib cotreatment on HCC cells were stronger than those of either drug alone. In addition, combined treatment with the two drugs synergistically inhibited epithelial–mesenchymal transition and the Akt pathway but not NF-κB or MAPK signaling. Akt phosphorylation by SC79 reversed the inhibitory effects of the combined treatment. Synergistic inhibition was equally observed in vivo.

Conclusion

Oridonin combined with sorafenib synergistically inhibited proliferation, migration, invasion, and epithelial–mesenchymal transition and induced apoptosis by targeting the Akt pathway but not NF-κB or MAPK signaling.

Long-term and short-term surgical outcomes of single-incision laparoscopic hepatectomy on anterolateral liver segments

BACKGROUND

Laparoscopic liver resection yields improved short-term surgical outcomes, whereas the reports about clinical benefits of single-incision laparoscopic hepatectomy (SILH) are scarce. This retrospective study is to compare the surgical outcomes of SILH with those of multi-incision laparoscopic hepatectomy (MILH).

METHODS

The study included 54 patients who had undergone SILH and 184 patients who had undergone MILH between January 2010 and December 2017. Short-term outcomes were compared in those of patients who underwent left lateral sectionectomy and partial hepatectomy of segment 5-6. A subgroup analysis of hepatocellular carcinoma (HCC) was also performed for long-term outcome comparisons.

RESULTS

In those of patients who underwent left lateral sectionectomy, SILH group had less chronic hepatitis B (15.2 vs. 45.8%; p = 0.004), less liver cirrhosis (12.1 vs. 50.0%; p = 0.002), less tumor proximal to major vessel (6.1 vs. 29.2%; p = 0.018), shorter surgical time (113.2 ± 37.9 vs. 146.0 ± 50.5 min; p = 0.007), and shorter postoperative hospital stays (4.4 ± 1.1 vs. 5.4 ± 1.3 days; p = 0.002) compared with MILH group. In those of patients with tumor located at segment 5-6, no significant differences were observed in surgical time, blood loss, complications, and mortality. Single-incision laparoscopic partial hepatectomy was only associated with wider surgical margins (11.8 ± 7.0 vs. 5.3 ± 5.2 mm; p = 0.003). In the HCC subgroup, SILH had similar 1-, 3-, and 5-year overall survival and 1-, 3-, and 5-year recurrence-free survival rates compared with patients who had undergone MILH.

CONCLUSIONS

The study demonstrates the safety and feasibility of single-incision laparoscopic liver resection for left lateral sectionectomy and partial hepatectomy for segment 5-6. In selected patients within the group and by experienced surgical team, the SILH technique results in comparable short-term surgical outcomes and long-term oncological outcomes.

Laparoscopic repeat hepatectomy is a more favorable treatment than open repeat hepatectomy for contralateral recurrent hepatocellular carcinoma cases

BACKGROUND

We compared surgical outcomes, with a focus on tumor characteristics, of laparoscopic repeat hepatectomy (LRH) and open repeat hepatectomy (ORH) to identify recurrent hepatocellular carcinoma (HCC) cases where the LRH procedure would be more favorable than ORH.

METHODS

Eighty-one HCC patients who underwent repeat hepatectomy in our hospital from 2008 to 2019 were retrospectively analyzed in this study. Of these patients, 30 and 51 patients underwent LRH and ORH, respectively. We analyzed surgical outcomes of LRH and ORH, focusing on tumor characteristics such as tumor size, location, distance from major vessels, and contralateral or ipsilateral tumor recurrence to determine what factors could affect surgical outcomes. Subsequently, using a propensity-matched cohort, we compared the impact of those factors on LRH and ORH outcomes.

RESULTS

In the entire cohort, the LRH operation time was significantly shorter in contralateral recurrent HCC cases than in ipsilateral recurrent HCC cases (252 vs. 398 min, P = 0.008); however, such a difference was not observed in the ORH operation time. We subsequently compared the surgical outcomes, in terms of the location of tumor recurrence, between the LRH and ORH groups in a propensity-matched cohort. In total, 23 patients were included in each of these groups. We found that the LRH procedure had significantly shorter operative time than the ORH procedure in the contralateral recurrent HCC cases (253 vs. 391 min, P = 0.018); however, we did not observe such a difference in the ipsilateral recurrent HCC cases (372 vs. 333 min, P = 0.669). LRH had lower blood loss, similar postoperative complications and shorter hospital stay than ORH in both contralateral and ipsilateral recurrent HCC cases.

CONCLUSIONS

LRH is likely considered a more favorable approach than ORH in treating patients with contralateral recurrent HCC.

Perioperative outcomes comparing laparoscopic with open repeat liver resection for post-hepatectomy recurrent liver cancer: A systematic review and meta-analysis

BACKGROUND

Repeat laparoscopic hepatectomy (LRH) offers an option for recurrent tumors in liver remnants following an initial liver resection of recurrent hepatocellular carcinoma (HCC), colorectal liver metastasis (CRLM) and cholangiocellular carcinoma (CCC), showing advantages in some outcomes. The objective of the study was to evaluate the feasibility, safety, and potential benefits of LRH in comparison with repeat open hepatectomy (ORH) for recurrent liver cancer.

METHODS

A systematic review was performed in compliance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) and AMSTAR (Assessing the methodological quality of systematic reviews) guidelines. We performed a systematic search of PubMed, Embase, Cochrane Library, and Web of Science to identify studies that compared LRH with ORH from inception to September 30, 2019. Outcomes of interest included operation time, intraoperative estimated blood loss, length of hospital stay, complication rate, transfusion and R0 resection rate. The protocol was registered with the PROSPERO register of systematic reviews.

RESULTS

10 retrospective observational studies were suitable for this analysis, involving 767 patients with 334 undergoing LRH (43.5%) and 433 undergoing ORH (56.5%). Compared with ORH, LRH had less intraoperative blood loss (SMD = -1.03; 95% CI: 1.48~-0.59, P < 0.001), less overall postoperative complications (OR = 0.40; 95% CI: 0.16-0.99, P = 0.048), less major complications (OR = 0.31, 95% CI: 0.15-0.62, P = 0.001), shorter hospital stay (SMD = -0.98; 95% CI: 1.41~-0.54, P < 0.001) and higher R0 resection rate (OR = 2.30, 95% CI: 1.39-3.81, P = 0.001). It was comparable in operation time (WMD = -7.66; 95% CI: 52.50-37.19, P = 0.738), transfusion rate (OR = 0.33; 95% CI:0.11-1.05, P = 0.060), and mortality (OR = 0.76; 95% CI: 0.27-2.18, P = 0.615) between LRH and ORH.

CONCLUSION

Our results indicate that LRH is a safe and effective technique. Benefits, especially less intra-operative blood loss, less complications rate, shorter hospital stay and higher R0 resection, might be offered in the laparoscopic approach.

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.

Comparison of clinical outcomes of laparoscopic versus open surgery for recurrent hepatocellular carcinoma: a meta-analysis

BACKGROUND

The purpose of this study is to compare the clinical outcomes of laparoscopic liver resection versus open liver resection for recurrent hepatocellular carcinoma (RHCC).

METHODS

Published studies which investigated laparoscopic versus open liver resection for RHCC were identified, and meta-analysis was used for statistical analysis.

RESULTS

Six studies were analyzed by meta-analysis method, and cumulative 335 cases were included in this study. Laparoscopic liver resection was performed in 145 cases, and open liver resection was performed in 190 cases. Meta-analysis showed that there was no difference in operative time and 90-day mortality between the laparoscopic group and the open group (p = 0.06 and p = 0.06 respectively); Nevertheless, compared with the open group, the laparoscopic group resulted in significantly lower rate of in-hospital complication (p < 0.0001), much less blood loss (p < 0.0001) and shorter postoperative hospital stay (p = 0.002).

CONCLUSION

Laparoscopic liver resection for RHCC offers a benefit of lower in-hospital complication rate, less blood loss, shorter postoperative hospital stay, while similar operative time and 90-day mortality as the open liver resection. Laparoscopic liver resection is feasible with satisfactory postoperative outcomes and can be a safe alternative treatment strategy to open procedure for RHCC.

Standardization of operative technique in minimally invasive right hepatectomy: improving cost-value relationship through value stream mapping in hepatobiliary surgery

BACKGROUND

With current emphasis on improving cost-quality relationship in medicine, it is imperative to evaluate cost-value relationships for surgical procedures. Previously the authors demonstrated comparable clinical outcomes for minimally invasive right hepatectomy (MIRH) and open right hepatectomy (ORH). MIRH had significantly higher intraoperative cost, though overall costs were similar.

METHODS

MIRH was decoded into its component critical steps using value stream mapping, analyzing each associated cost. MIRH technique was prospectively modified, targeting high cost steps and outcomes were re-examined. Records were reviewed for elective MIRH before (pre-MIRH n = 50), after (post MIRH n = 25) intervention and ORH (n = 98), between January 1, 2008 and November 30, 2016.

RESULTS

Average overall cost was significantly lower for post-standardization MIRH (post-MIRH $21 768, pre-MIRH $28 066, ORH $33 020; p < 0.001). Average intraoperative blood loss was reduced with MIRH (167, 292 and 509 mL p < 0.001). Operative times were shorter (147, 190 and 229 min p < 0.001) and LOS was reduced for MIRH (3, 4, 7 days p < 0.002).

CONCLUSIONS

Using a common quality improvement tool, the authors established a model for cost effective clinical care. These tools allow surgeons to overcome personal or traditional biases such as stapler choices, but most importantly eliminate non-value added interventions for patients.

Safety and feasibility of laparoscopic liver resection for patients with previous upper abdominal surgery: A systematic review and meta-analysis

BACKGROUND

Laparoscopic hepatectomy (LH) is technical challenge for patients with previous upper abdominal surgery (UAS), especially for those with previous liver resection. The purpose of this meta-analysis is to assess the safety and feasibility of laparoscopic liver resection for patients with previous UAS, in comparison with primary laparoscopic liver resection which means patients without previous upper abdominal surgery (non-UAS).

METHODS

All case-matched articles published from date of inception to 15th April 2018 were identified independently by two reviewers. Perioperative outcomes were analyzed. Data were extracted and calculated by random- or fixed-effect models. In addition, subgroup analysis according to patients with history of liver resection was performed.

RESULTS

A total of 8 non-randomized observational articles were included, with 1625 patients (430 patients in UAS group and 1195 in non-UAS group). The results showed that there was no significant difference between the two groups in perioperative outcomes. In the subgroup analysis of patients with a history of liver resection, however, LH for patients with previous liver resection had longer operative time comparing with patients without previous liver resection (WMD = 33.03, 95% CI 3.16 to 62.90, P = 0.030); other perioperative outcomes were similar between UAS and non-UAS groups.

CONCLUSION

LH is feasible and safe for selected patients with previous UAS comparing with that of primary resection, although LH has longer operative time for patients with previous liver resection.

Short-term outcomes of laparoscopic repeat liver resection after open liver resection: a systematic review

BACKGROUND

Laparoscopic repeat liver resection (LRLR) still represents a challenge for surgeons especially in case with previous open liver surgery. The aim of the study is to perform a systematic review of the current literature to investigate the feasibility of LRLR after open liver resection (OLR) for liver diseases.

METHODS

A computerized search was performed for all English language studies evaluating LRLR. A meta-analysis was performed to evaluate the short-term outcomes in comparative studies between LRLR with previous laparoscopic liver resection (LLR) and OLR.

RESULTS

From the initial 55 manuscripts, 8 studies including 3 comparative studies between LRLR after OLR and LLR were investigated. There was a total of 108 patients. Considering initial surgery, the extent of initial liver resection was major liver resection in 20% of patients in whom it was reported. In all the patients, the most frequent primary histology was hepatocellular carcinoma, followed by colorectal liver metastasis. A half of reported patients had severe adhesions at the time of LRLR. The median operative time for LRLR was ranged from 120 to 413 min and the median blood loss ranged from 100 to 400 mL. There were 11% of the patients conversions to open surgery, hand-assisted laparoscopic surgery, or tumor ablation. The overall postoperative morbidity was 15% of all the patients, and there was no postoperative mortality. The median postoperative hospital stay was ranged from 3.5 to 10 days. The meta-analysis shows that LRLR after OLR is associated with a longer operative time and a more important blood loss compared to LRLR after LLR. However, no difference between LRLR after OLR and LLR was shown as far as hospital stay and morbidity rate are concerned.

CONCLUSIONS

LRLR after OLR has been described in eight articles with favorable short-term outcomes in highly selected patients.

Systematic review and meta-analysis of laparoscopic versus open repeat hepatectomy for recurrent liver cancer

BACKGROUND

Repeat hepatectomy plays a key role in recurrent hepatic tumors. However, it is still unknown whether laparoscopic hepatectomy is suitable for recurrent liver cancers. The aim of this meta-analysis is to evaluate the efficacy and feasibility of laparoscopic repeat hepatectomy (LRH) compared with open repeat hepatectomy (ORH).

METHODS

Several databases, including Web of Science, PubMed, The Cochrane Library and Ovid, were retrieved from date of inception to 31st March 2018. All articles comparing LRH and ORH were identified. Tumor characteristics and perioperative outcomes including resection type, operation time, blood loss, transfusion, complications and hospital stay were evaluated. Data were extracted and calculated using random- or fixed-effect models.

RESULTS

A total of seven non-randomized observational clinical articles including 443 patients were analyzed. LRH was associated with significantly lower blood loss (WMD = -389.09, 95% CI -628.34 to -149.84, P = 0.001), transfusion (OR 0.16, 95% CI 0.03-0.74, P = 0.019) as well as limited hospital stay (WMD = -4.00, 95% CI -6.58 to -1.42, P = 0.002). No statistical difference was found in the field of tumor characteristics and other perioperative outcomes. In the sensitivity analysis of case-match studies, LRH was associated with significant limited hospital stay, but with significant longer operation time. There were 8 (1.8%, range 0-13.3%) cases of conversion in LRH group.

CONCLUSIONS

Based on the results of these limited data, LRH is as feasible and efficient as ORH by expert surgeons in selected patients, whose cancer is resectable at the time of surgery and who have Child-Pugh A or B cirrhosis.

Perioperative Outcomes of Laparoscopic Repeat Liver Resection for Recurrent HCC: Comparison with Open Repeat Liver Resection for Recurrent HCC and Laparoscopic Resection for Primary HCC

BACKGROUND

This study aims to determine the safety and efficacy of laparoscopic repeat liver resection (LRLR) for recurrent hepatocellular carcinoma (rHCC).

METHODS

Twenty patients underwent LRLR for rHCC between 2015 and 2017. The control groups consisted of 79 open RLR (ORLR) for rHCC and 185 LLR for primary HCC. We undertook propensity score-adjusted analyses (PSA) and 1:1 propensity score matching (PSM) for the comparison of LRLR versus ORLR. Comparison of LRLR versus LLR was done using multivariable regression models with adjustment for clinically relevant covariates.

RESULTS

Twenty patients underwent LRLR with three open conversions (15%). Both PSA and 1:1-PSM demonstrated that LRLR was significantly associated with a shorter stay, superior disease-free survival (DFS) but longer operation time compared to ORLR. Comparison between LRLR versus LLR demonstrated that patients undergoing LRLR were significantly older, had smaller tumors, longer operation time and decreased frequency of Pringle's maneuver applied. There was no difference in other key perioperative outcomes.

CONCLUSION

The results of this study demonstrate that in highly selected patients; LRLR for rHCC is feasible and safe. LRLR was associated with a shorter hospitalization but longer operation time compared to ORLR. Moreover, other than a longer operation time, LRLR was associated with similar perioperative outcomes compared to LLR for primary HCC.

Perioperative and long-term outcomes of laparoscopic versus open liver resection for hepatocellular carcinoma with well-preserved liver function and cirrhotic background: a propensity score matching study

BACKGROUND

Although laparoscopic liver resection (LLR) has advanced into a safe and effective alternative to conventional open liver resection (OLR), it has not been widely accepted by surgeons. This article aimed to investigate the perioperative and long-term benefits of LLR versus OLR for hepatocellular carcinoma (HCC) in selected patients with well-preserved liver function and cirrhotic background.

METHODS

A retrospective study was conducted on 1085 patients with HCC who underwent liver resection at Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University from July 2010 to July 2015, and 346 patients with well-preserved liver function and cirrhotic background were selected. A 1:1 propensity score matching (PSM), which is the best option to overcome selection bias, was conducted to compare the surgical outcomes and long-term prognosis between LLR and OLR. After PSM, a logistic regression analysis was used to identify the predictive risk factors of posthepatectomy liver failure (PHLF).

RESULTS

By using PSM, the two groups were well balanced with 86 patients in each group. In the LLR group, only the median operation time was significantly longer than the OLR group, but the hospital stay, overall morbidity, and the incidence of PHLF were significantly decreased compared to OLR. There were no significant differences in the overall survival and disease-free survival rates between the two groups. On multivariate analysis, OLR was identified to be the only independent risk factor for PHLF.

CONCLUSIONS

In selected HCC patients with well-preserved liver function and cirrhotic background, LLR could be a better option compared to OLR.

Laparoscopic liver resection for large HCC: short- and long-term outcomes in relation to tumor size

OBJECTIVE

In this study, we aim to assess the impact of tumor size on clinical and oncological outcomes in patients undergoing laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC).

BACKGROUND

LLR has been shown to be feasible, safe, and oncologically efficient. However, it has been slow to develop in patients with HCC who often suffer from chronic liver disease which represents an additional challenge for the surgeon. The experience with large HCCs is even more limited.

METHODS

Between 2003 and 2016, 172 patients from two high-volume liver surgery centers underwent LLR for HCC. Prospectively collected data were analyzed after stratification in 3 groups according to tumor major diameter (group 1: < 3 cm; group 2: between 3 and 5 cm; group 3: ≥ 5 cm). Perioperative and long-term outcomes were compared between the three groups and sub-analyses were carried out on the extent and location of the resections.

RESULTS

Groups 1, 2, and 3 consisted of 82, 52, and 38 patients, respectively. Minor and major resections were performed in 98.8% and 1.2% in group 1, in 90.4% and 9.6% in group 2, and in 68.4% and 31.6% in group 3, respectively. Postero-superior "technically major" resections were performed in 15.8% patients in group 1, in 19.2% in group 2, and in 15.8% in group 3, respectively. Group 3 had higher conversion rates (p < 0.001), more frequent (p = 0.056) and more prolonged (p = 0,075) pedicle clamping and longer operative time (p < 0.001), higher blood losses (p = 0.025), and longer total hospital and intensive care unit stays. These differences ceased after removing the major resections from the study population, except for the postoperative length of stay. There were no differences in morbidity, mortality, completeness of resection rates, and long-term outcomes between the three groups.

CONCLUSION

LLR for HCC appears to be safe and oncologically efficient when performed in high-volume HPB and laparoscopic centers. Tumor size does not appear to impact negatively on the outcomes except for postoperative hospital stay.

Multidisciplinary management of recurrent and metastatic hepatocellular carcinoma after resection: an international expert consensus

Hepatocellular carcinoma (HCC) is the sixth-most common cancer and the third leading cause of cancer-related death in the world. However, 40-70% patients eventually suffer from postoperative recurrence within 5 years. HCC recurrence after surgery severely affects prognosis of the patients. Nevertheless, there is an opportunity to improve patients' prognosis if doctors and researchers can recognize the importance of a standardized perioperative management and study it in clinical and pre-clinical settings. Hence, based on our own experience and published studies from other researchers, we develop this consensus regarding multidisciplinary management of locally recurrent and metastatic hepatocellular carcinoma after resection. This consensus consists of the entire course of recurrent hepatocellular carcinoma (RHCC) management, including prediction of recurrence, prevention, diagnosis, treatment and surveillance of RHCC. Consensus recommendations are presented with grades of evidences (Ia, Ib, IIa, IIb, III and IV), and strength of recommendations (A, B, C, D and E). We also develop a decision-making path for RHCC treatment, which can intuitively demonstrate the management for RHCC. It is hoped that we may make some effort to standardize the management of RHCC and ultimately understand how to improve outcomes.

Long-term and short-term surgical outcomes of laparoscopic versus open liver resection for hepatocellular carcinoma: might laparoscopic approach be better in early HCC?

BACKGROUND

This retrospective study compared the short- and long-term outcomes of laparoscopic liver resection (LLR) and open liver resection (OLR) and identified patients who might gain more benefits from LLR.

METHODS

The demographic and perioperative data, short-term surgical outcomes, and long-term oncological results of all 313 patients who received elective liver resection for hepatocellular carcinoma (HCC) between January 2010 and June 2017 were analyzed. The patients were then divided into stage-specific subgroups according to the TNM staging system for comparison.

RESULTS

LLR was performed in 153 patients and OLR in 160 patients. LLR is associated with less blood loss (p < 0.001), shorter surgical time (p = 0.001), shorter length of hospital stay (p < 0.001), and lower morbidity rate (p = 0.034). The 5-year overall survival (OS) rates in the LLR group were higher than those in the OLR group (78.1 vs. 57.6%; p = 0.002). Stage-specific subgroup analysis revealed similar 5-year OS in the two groups (stage I: 82.8 vs. 82.6%, p = 0.845; stage II: 80.3 vs. 69.2%, p = 0.638; stage III: 55.6 vs. 34.8%, p = 0.681), as did the 5-year recurrence-free survival. Moreover, the short-term outcomes were better in the LLR group in terms of surgical time, blood loss, and length of hospital stay, and these benefits attenuated with advancing tumor stage.

CONCLUSIONS

LLR for HCC is a safe and feasible procedure that does not compromise long-term oncological outcomes. In early tumor stages, LLR might be better in terms of short-term surgical outcomes.