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

Short-term outcomes of laparoscopic central hepatectomy: a comparison with open surgery

PURPOSE

Laparoscopic liver resection has advantages over open liver resection, including reduced blood loss and shorter hospital stays. Laparoscopic central hepatectomy (CH) is a highly challenging procedure, and such outcomes can only be achieved with a high level of expertise in laparoscopic liver surgery. Laparoscopic CH remains challenging, with safety and efficacy unclear. This study retrospectively evaluated the intra- and short-term outcomes of laparoscopic versus open CH and assessed safety and efficacy of laparoscopic surgery.

METHODS

CH included anterior sectionectomy (AS) and central bisectionectomy (CBS) (excluding cases with biliary reconstruction). The study comprised 38 patients receiving CH in our department from January 2010 to November 2023.

RESULTS

The laparoscopic group included 14 cases and the open group 24. AS/CBS was performed in 14/10 open group cases and 6/8 laparoscopic group cases. Short-term surgical outcomes showed no significant between-group difference in operative time, but the laparoscopic group lost significantly less blood (250 vs. 985 mL; p = 0.001) and the transfusion rate was lower (14% vs. 46%; p = 0.004). Among postoperative outcomes, incidence of bile leakage was not significantly different (33% vs. 42%; p = 0.42), but the laparoscopic group had significantly less postoperative ascites (0% vs. 17%; p = 0.047), fewer surgical site infections (SSI) (0% vs. 21%; p = 0.02), and shorter postoperative hospital stay (14 vs. 30 days; p = 0.005). The risk factor for bile leakage in CH by univariate and multivariate analysis was tumor proximity to the right anterior Glissonean pedicle (OR = 6.84; 95% CI = 1.67-32.7; p = 0.01).

CONCLUSION

Laparoscopic CH could be performed safely. Compared to open surgery, laparoscopic CH was effective in reducing blood loss, postoperative ascites, SSIs, and shortening postoperative hospital stay. However, tumors close to the root of the right anterior Glissonean pedicle were considered a risk factor for postoperative bile leakage and require caution.

Laparoscopic central hepatectomy: Feasibility and safety

BACKGROUND

Anatomical liver resection is the gold standard for hepatocellular carcinoma (HCC), enhancing survival and disease-free outcomes. For centrally located tumors, major resections are necessary but risky, especially for patients with liver disease. Central hepatectomy (CH) offers a parenchymal-sparing alternative to extended or hemihepatectomy (HH), reducing postoperative liver failure risk. However, its complexity and the large transection area make it challenging, especially with laparoscopic techniques. This study evaluates the feasibility and safety of laparoscopic CH for centrally located HCC, comparing surgical outcomes with those of the HH group.

METHODS

A total of 1592 laparoscopic hepatectomy cases from January 2011 to April 2023 were reviewed in a single institution. Patients undergoing laparoscopic CH were compared to those receiving HH during the same period. Exclusion criteria included non-HCC diagnosis, non-central tumors, and cases involving combined procedures.

RESULTS

70 cases of laparoscopic CH and 32 cases of laparoscopic HH were included. The CH and HH groups showed similar estimated blood loss (median 400 ml vs. 290 ml, p = 0.187) and intraoperative blood transfusion rates (10% vs. 15%, p = 0.413). Operation time did not significantly differ (median 330 min vs. 360 min, p = 0.862). Postoperative hospital stay was shorter in CH (median 6 days vs. 9 days, p = 0.018), with fewer ICU transfers (19% vs. 44%, p = 0.014) and lower 90-day mortality (1% vs. 9%, p = 0.055) compared to HH. Complication rates were similar overall (26% vs. 41%, p = 0.069), but HH had more Clavien-Dindo class I and II complications (13% vs. 19%, p = 0.040). Long-term survival did not significantly differ, but tended to favor the CH group.

CONCLUSION

Despite the complexity, laparoscopic CH offers comparable perioperative outcomes and favorable long-term survival compared to HH. It can be considered a viable option for centrally located HCC, preserving liver function.

Different Approaches of Laparoscopic Mesohepatectomy for Centrally Located Hepatocellular Carcinomas

BACKGROUND

This study aimed to describe a simple and novel positional classification system for centrally located hepatocellular carcinoma (CL-HCC), based on which different surgical approaches for laparoscopic mesohepatectomy (LMH) were chosen.

MATERIALS AND METHODS

The data of patients with CL-HCC who underwent LMH between January 2017 and December 2021 were retrospectively analyzed. The positional classification method was used to locate tumors. In addition, different approaches were used during the surgery according to the classification type.

RESULTS

All 98 patients underwent LMH, of whom 4 were converted to open surgery. Types I, Ⅱ, and Ⅲ were 24, 37, and 37, respectively. Blood transfusions were performed in only 7 patients, of which the amount was 800 (600, 900) mL. All the patients underwent R0 resection. The complication rate was 9.2% in all cases. No deaths occurred.

CONCLUSIONS

Our proposed classification system and corresponding surgical approach in LMH is conducive to the successful completion of surgery.

Safety and Perioperative Outcomes of Laparoscopic vs. Open Hepatectomy of Central-Located Liver Lesions: A Multicenter, Propensity Score-Matched, Retrospective Cohort Study

Background: Short-term outcomes of laparoscopic hepatectomy of central-located liver lesions (LHCL) compared with traditional open hepatectomy of central-located liver lesions (OHCL) remain unclear. The aim of this study was to explore the safety and efficacy of LHCL. Methods: A retrospective analysis was performed on 262 patients who underwent hepatectomies involving resections of liver segment II, IV or VIII from January 2015 to June 2021 in two institutions. Patients in the LHCL group were matched in a 1:2 ratio to patients in the OHCL group. Results: After propensity score-matched (PSM) analysis, 61 patients remained in the LHCL group and 122 patients were in the OHCL group. What needs to be mentioned is that although not significant, patients in the OHCL group had increased lesion size (4.3 vs. 3.6 cm, p = 0.052), number (single/multiple, 84.8%/15.2% vs. 93.4%/6.6%, p = 0.097), and number of liver segments involved (one/two/three, 47.3%/42.0%/10.7% vs. 57.4%36.1%/10.7%, p = 0.393). To ensure surgical safety, fewer patients in the LHCL group underwent vascular exclusion than those in the OHCL group (p = 0.004). In addition, LHCL was associated with lower blood loss (p = 0.001) and transfusion requirement (p = 0.004). In terms of short-term outcomes, the LHCL group had significantly lower levels of peak ALT (p < 0.001), peak DBIL (p = 0.042), peak PT (p = 0.012), and higher levels of bottom ALB (p = 0.049). Moreover, the LHCL group demonstrated quicker postoperative recovery, which was represented by shorter time to first flatus, time to oral intake, time to drain off, and hospital stay (all p < 0.001). Importantly, the LHCL group had a significantly reduced occurrence of postoperative complications (p < 0.001) and similar R0 resection rates (p = 0.678) when compared to the OHCL group. Conclusion: LHCL is associated with increased safety and better perioperative outcomes and thus could be recommended for patients with central space-occupying liver lesions when appropriately selecting the surgical procedure according to the total tumor burden and carefully handled by experienced surgeons. From the experience of our center, LHCL could be performed to solitary lesion involving liver segment IV/V/VIII, <5 cm, with good safety and feasibility.

Positioning of Minimally Invasive Liver Surgery for Hepatocellular Carcinoma: From Laparoscopic to Robot-Assisted Liver Resection

Laparoscopic liver resection (LLR) is widely accepted in the surgical treatment of hepatocellular carcinoma (HCC) through international consensus conferences and the development of difficulty classifications. LLR has been reported to result in earlier postoperative recovery and fewer postoperative complications than open liver resection (OLR) for HCC. However, the prevalence of liver cirrhosis, obesity, the elderly, HCC recurrence (repeat liver resection), and major resection must be considered for LLR for HCC. Some systematic reviews, meta-analysis studies, and large cohort studies indicated that LLR is technically feasible for selected patients with HCC with these factors that led to less intraoperative blood loss, fewer transfusions and postoperative complication incidences, and shorter hospital stays than OLR. Furthermore, some reported LLR prevents postoperative loss of independence. No difference was reported in long-term outcomes among patients with HCC who underwent LLR and OLR; however, some recent reports indicated better long-term outcomes with LLR. In recent years, robot-assisted liver resection (RALR) has gradually become popular, and its short- and long-term results for HCC are not different from those of LLR. Additionally, RALR is expected to become the mainstay of minimally invasive surgery in the future.

Comparison of survival and post-operation outcomes for minimally invasive versus open hepatectomy in hepatocellular carcinoma: A systematic review and meta-analysis of case-matched studies

Background

With the rapid development of minimally invasive techniques and instruments, more and more patients begin to accept minimally invasive surgery. Minimally invasive hepatectomy (MIH) has obvious advantages in terms of surgical incision, but there is still no strong evidence of its long-term survival effect.

Purpose

The primary objective of this study was to compare long-term survival outcomes between MIH and Open hepatectomy (OH) in hepatocellular carcinoma based on high-quality case-control studies.

Methods

The study on the comparison of MIH (including RH or LH) and OH in the treatment of HCC from the date of establishment to June 1, 2022 was searched through PubMed, Web of Science, Embase and Cochrane Library databases. The main results were long-term overall and disease-free survival and short-term postoperative effect; All studies were conducted according to PRISMA guidelines, and meta-analysis of random effect models was adopted.

Results

43 articles included 6673 patients. In these studies, the data from 44 studies need to be extracted and pooled in the meta-analysis. Our results showed that compared with OH group, OS (HR 1.17; 95%CI 1.02, 1.35; P=0.02) and DFS (HR 1.15; 95%CI 1.05, 1.26; P=0.002) in MIH group were slightly lower than those in OH group. The operation time (Z=2.14, P=0.03, MD8.01, 95% CI: 2.60–13.42) was longer than OH group. In terms of length of hospital stay (Z=10.76, p&lt;0.00001, MD -4.0, 95% CI: -4.72 to -3.27), intraoperative blood loss (Z=5.33, P&lt;0.00001, MD -108.33, 95% CI: -148.15 to -68.50), blood transfusion rate (Z=5.06, p&lt;0.00001, OR=0.64, 95% CI 0.54 to 0.76, I2 = 0%), postoperative complications (Z=9.24, p&lt;0.00001, OR = 0.46, 95% CI 0.39 to 0.55, I2 = 21%), major morbidity (Z=6.11, p&lt;0.00001, OR=0.46, 95% CI 0.39 to 0.59,I2 = 0%), R0 resection (Z=2.34, P=0.02, OR=1.46, 95% CI 1.06 to 2.0, I2 = 0%) and mortality(Z=2.71,P=0.007, OR=0.56, 95% CI 0.37 to 0.85), the MIH group was significantly better than the OH group. The meta-analysis showed no significant difference in terms of major hepatectomy Z=0.47, P=0.64, OR=1.04, 95% CI 0.89 to 1.22, I2 = 0%), anatomical resection (Z=0.48, P=0.63, OR=0.92, 95%CI 0.67 to 1.27), satellite nodules (Z=0.54, P=0.59, OR=0.92, 95%CI 0.69 to 1.23, I2 = 0%), microvascular invasion (Z=1.15, P=0.25, OR=1.11, 95%CI 0.93 to 1.34, I2 = 0%) and recurrence (Z=0.71, p=0.48, OR=0.94, 95% CI 0.78 to 1.12, I2 = 19%).

Conclusion

This study is the first to compare the clinical efficacy of MIH and OH in the treatment of HCC based on a high-quality propensity score matching study. The results show that in terms of long-term survival outcomes (OS and DFS), although the gap between MIH and OH is not obvious, OH was better than MIH on the whole. However, in terms of short-term postoperative outcomes (post-operation outcomes), MIH was slightly better than OH.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022332556.

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.

Minimally Invasive vs Open Major Hepatectomies for Liver Malignancies: a Propensity Score-Matched Analysis

BACKGROUND

The majority of evidence with regards to minimally invasive liver resection (MILR) favors its application in minor hepatectomies. We conducted a propensity score-matched (PSM) analysis to determine its feasibility and safety in major hepatectomies (MIMH) for liver malignancies.

METHODS

Retrospective review of 130 patients who underwent MIMH and 490 patients who underwent open major hepatectomy (OMH) for malignant pathologies was performed. PSM in a 1:1 ratio identified two groups of patients with similar baseline clinicopathological characteristics. Perioperative outcomes were then compared. Major hepatectomies included traditional major (>3 segments) and technical major hepatectomies (right anterior and right posterior sectionectomies).

RESULTS

Both cohorts were well-matched for baseline characteristics after PSM. Of 130 MIMH cases, there were 12 conversions to open. Comparison of perioperative outcomes demonstrated a significant association of MIMH with longer operation time and more frequent application of Pringle's maneuver (PM), but decreased postoperative stay. These results were consistent on a subgroup analysis that only included patients undergoing traditional major hepatectomies. A second subgroup analysis restricted to cirrhotic patients demonstrated that while perioperative outcomes were equivalent, MIMH was similarly associated with a longer operative time. Subset analyses of resections performed after 2015 demonstrated that MIMH was additionally associated with a lower postoperative morbidity compared to OMH.

CONCLUSION

Comparison of perioperative and short-term oncological outcomes between MIMH and OMH for malignancies demonstrated that MIMH is feasible and safe. It is associated with a shorter hospital stay at the expense of a longer operation time compared to OMH.

Minimally invasive mesohepatectomy for centrally located liver lesions-a case series

BACKGROUND

Resection of centrally located liver lesions remains a technically demanding procedure. To date, there are limited data on the effectiveness and safety of minimally invasive mesohepatectomy for benign and malignant lesions. It was therefore the objective of this study to evaluate the perioperative outcomes of minimally invasive mesohepatectomy for liver tumors at a tertiary care hospital.

METHODS

Consecutive patients who underwent a minimally invasive anatomic mesohepatectomy using a Glissonean pedicle approach from April 2018 to November 2021 were identified from a prospective database. Demographics, operative details, and postoperative outcomes were analyzed using descriptive statistics for continuous and categorical variables.

RESULTS

A total of ten patients were included, of whom five patients had hepatocellular carcinoma, one patient had cholangiocarcinoma, three patients had colorectal liver metastases, and one patient had a hydatid cyst. Two and eight patients underwent robotic-assisted and laparoscopic resections, respectively. The median operative time was 393 min (interquartile range (IQR) 298-573 min). Conversion to laparotomy was required in one case. The median lesion size was 60 mm and all cases had negative resection margins on final histopathological analysis. The median total blood loss was 550 ml (IQR 413-850 ml). One patient had a grade III complication. The median length of stay was 7 days (IQR 5-12 days). Time-to-functional recovery was achieved after a median of 2 days (IQR 1-4 days). There were no readmissions within 90 days after surgery.

CONCLUSION

Minimally invasive mesohepatectomy is a feasible and safe approach in selected patients with benign and malignant liver lesions.

Long-term survival outcome of laparoscopic liver resection for hepatocellular carcinoma

Long-term survival is the most important outcome measurement of a curative oncological treatment. For hepatocellular carcinoma (HCC), the long-term disease-free and overall survival of laparoscopic liver resection (LLR) is shown to be non-inferior to the current standard of open liver resection (OLR). Some studies have reported a superior long-term oncological outcome in LLR when compared to OLR. It has been argued that improvement of visualization and instrumentation and reduced operative blood loss and perioperative blood transfusion may contribute to reduced risk of postoperative tumor recurrence. On the other hand, since most of the comparative studies of the oncological outcomes of LLR and OLR for HCC are non-randomized, it remained inconclusive as to whether LLR confers additional survival benefit compared to OLR. Despite the paucity of level 1 evidence, the practice of LLR for HCC has gained wide-spread acceptance due to the reproducible improvements in the perioperative outcomes and non-inferior oncological outcomes demonstrated by large-scaled, matched comparative studies. Meta-analyses of the outcomes of these studies by multiple systematic reviews have also returned noncontradictory conclusions. On the basis of a theoretical advantage of LLR over OLR in preventing tumor recurrence, the current review aims to dissect from the current meta-analyses and comparative studies any evidence of such superiority.

Does minimally invasive liver resection improve long-term survival compared to open resection for hepatocellular carcinoma? A systematic review and meta-analysis

INTRODUCTION

Minimally invasive liver surgery for hepatocellular carcinoma has gained widespread interest as an alternative to conventional open liver surgery. However, long-term survival benefits of this approach seem unclear. This meta-analysis was conducted to investigate long-term survival following minimally invasive liver surgery.

METHOD

A systematic review was performed to identify studies comparing long-term survival after minimally invasive liver surgery and open liver surgery until January 2020. The I² test was used to test for statistical heterogeneity and publication bias was assessed using Egger test. Random-effects meta-analysis was performed for all-cause 5-year (main outcome) and 3-year mortality, and disease-specific 5-year and 3-year mortality. Meta-regression was performed for the 5-year and 3-year survival outcomes with adjustment for study factors (region, design), annual center volume, patient factors (American Society of Anesthesiologists (ASA) grade, gender, age, body mass index, cirrhosis, tumor size, and number), and resection extent. Sensitivity analyses were performed on studies by study year, region, annual center volume, and resection type.

RESULT

The review identified 50 relevant studies including 13,731 patients undergoing liver resection for hepatocellular carcinoma of which 4071 (25.8%) underwent minimally invasive liver surgery. Pooled analysis revealed similar all-cause (odds ratio: 0.83, 95% confidence interval: 0.70-1.11, p = 0.3) and disease-specific (odds ratio: 0.93, 95% confidence interval: 0.80-1.09, p = 0.4) 5-year mortality after minimally invasive liver surgery compared with open liver surgery. Sensitivity analysis of published studies from 2010 to 2019 demonstrated a significantly lower disease-specific 3-year mortality (odds ratio: 0.75, 95% confidence interval: 0.59-0.96, p = 0.022) and all-cause 5-year mortality (odds ratio: 0.63, 95% confidence interval: 0.50-0.81, p = 0.002). Meta-regression identified no confounding factors in all analyses.

CONCLUSIONS

Improvement in minimally invasive liver surgery techniques over the past decade appears to demonstrate superior disease-specific mortality with minimally invasive liver surgery compared to open liver surgery. Therefore, minimally invasive liver surgery can be recommended as an alternative surgical approach for hepatocellular carcinoma.

Survival analysis between laparoscopic and open hepatectomy for hepatocellular carcinoma: a meta-analysis based on reconstructed time-to-event data

BACKGROUND/PURPOSE OF THE STUDY

Laparoscopic hepatectomy (LH) has been widely used in the treatment of hepatocellular carcinoma (HCC). It is generally believed that the long-term outcomes of LH are not inferior to open hepatectomy (OH). However, the quality of evidence is low. The purpose of this study was to reconstruct time-to-event data for meta-analysis based on Kaplan-Meier curves from propensity-score matched studies and compare survival rates following LH and OH for hepatocellular carcinoma.

METHODS

All published propensity-score matched studies reported in English that compared LH and OH for hepatocellular carcinoma with Kaplan-Meier curves were screened. Patients' survival information was reconstructed with the aid of a computer vision program. Different models (fixed-effects model for two-stage survival analysis and Cox regression for one-stage survival analysis) were performed for sensitivity analysis. In addition to the primary meta-analysis, two specific subgroup analyses were performed on patients by types of resection, cirrhosis status.

RESULTS

Time-to-event data were extracted from 45 propensity-score matched studies (N = 8905). According to the time-to-event data and the reconstructed Kaplan-Meier curves, the cumulative overall survival rate was 49.0% and 50.9% in the LH and OH cohorts, respectively, a log-rank test did not demonstrate statistical significance (p > 0.05). The cumulative recurrence-free survival (RFS) probability was both close to 0.0%. The median RFS time was 49.1 (95% CI 46.1 ~ 51.7) and 44.3 (95% CI 41 ~ 46.1) months. The difference in disease status was statistically significant by the Log-rank test (p < 0.05). Using the random-effects model of two-stage analysis, the minor hepatectomy subgroup (HR = 1.32, 95% CI [1.09, 1.55], I² = 6.2%, p = 0.383) and the shared fragile model of one-stage analysis (HR = 1.44 95% CI [1.23, 1.69], p < 0.001) suggested that LH could significantly prolong RFS of patients compared with OH. This result was consistent with sensitivity analysis using different models.

CONCLUSION

This study was the first reconstructed time-to-event data based on a high-quality propensity-score matching study to compare the survival outcomes of LH and OH in the treatment of HCC. Results suggested that LH can improve RFS in patients with HCC undergoing minor hepatectomy and may also benefit long-term RFS in overall patients.

Minimally invasive versus open right anterior sectionectomy and central hepatectomy for central liver malignancies: a propensity-score-matched analysis

BACKGROUND

The utility of minimally-invasive liver resection (MILR) for deep centrally located tumours (CLT) remains controversial. We aimed to review our institution's experience and outcomes with minimally invasive central hepatectomy (CH) and right anterior sectionectomy (RAS) for CLT in a propensity score-matched (PSM) analysis.

METHODS

Retrospective review of a prospectively maintained surgical database revealed 23 patients who underwent MILR (6 CH, 17 RAS) and 53 patients who underwent open liver resection (OLR; 24 CH, 29 RAS) for CLT. PSM in a 1:1 ratio identified two groups of patients with similar baseline clinicopathological characteristics. Peri-operative outcomes were then compared.

RESULTS

There was one laparoscopic-assisted, one robot-assisted and two laparoscopic-converted-open procedures in the MILR cohort. Across the unmatched cohort, there was only one mortality (MILR) and five patients with major morbidity (all OLR). MILR was associated with a longer operating time (P < 0.001), but shorter post-operative hospital stay (P = 0.002) and decreased morbidity (P = 0.018) in the unmatched cohort. Examination of peri-operative outcomes after PSM revealed that MILR was similarly associated with a longer operating time (P = 0.001) and shortened post-operative hospital stay (P = 0.043). OLR was associated with a significantly reduced application of Pringle manoeuvre (P = 0.004). There were no significant differences between MILR and OLR with regards to blood loss, blood transfusions, morbidity and margin status in the PSM analysis.

CONCLUSION

MILR for CLT is safe and feasible when performed by experienced surgeons. It is associated with shorter hospital stays but at the expense of longer operation times and more frequent application of Pringle manoeuver.