Meta-analysis of laparoscopic versus open resection for hepatocellular carcinoma

Long-term outcomes of single-port laparoscopic hepatectomy for hepatocellular carcinoma: a retrospective comparative analysis

PURPOSE

Numerous efforts have been made to achieve minimally invasive surgery, such as single-port laparoscopic surgery. However, few studies have provided long-term follow-up information, and the number of patients with hepatocellular carcinoma (HCC) in previous studies has been small. The purpose in this study is to compare the long-term oncological outcomes of HCC patients who underwent single-port laparoscopic hepatectomy (SPLH) with those of patients who underwent multiport laparoscopic hepatectomy (MPLH).

METHODS

We retrospectively reviewed the medical records of 135 patients with HCC who underwent laparoscopic liver between January 2008 and December 2018. Of the 135 patients, 53 underwent MPLH, and 82 underwent SPLH.

RESULTS

From January 2008 to December 2018, 135 patients underwent laparoscopic hepatectomy for HCC. Among them, 82 patients underwent SPLH, and 53 patients underwent MPLH. Neither long-term overall survival (P = 0.849) nor recurrence-free survival (P = 0.057) differed significantly between the 2 groups, even though the recurrence rate was higher in the SPLH group. In the univariable analysis of risk factors for recurrence, multiple tumors, SPLH method, and portal vein invasion were statistically significant (P < 0.05). Multivariable analysis showed that the SPLH method and portal vein invasion were independent adverse prognostic factors for recurrence-free survival.

CONCLUSION

In terms of both short-term and long-term outcomes, the SPLH method seems to be a feasible approach for HCC in select patients. Because the potential risk of margin recurrence might produce poor oncological outcomes, strict patient selection is essential to ensure that an adequate safety margin can be secured.

Effect of minimally invasive versus open surgery in hepatectomy on postoperative wound complications in patients with hepatocellular carcinoma: A meta-analysis

In a meta-analysis, we assessed the impact of different surgical approaches on the outcome of hepatectomy with hepatocellular carcinoma. Four databases, including PubMed, Embase, Cochrane Library, and the Web of Science, have been critically reviewed through the full literature through June 2023. Eleven related trials were examined once they had met the trial's classification and exclusion criteria, as well as the assessment of the quality. A random effects approach was applied to analysis of operative organ infections, and a fixed-effect model was applied to determine the 95% CI and OR. Analysis of the data was done with RevMan 5.3. Our findings indicated that patients undergoing minimally invasive liver cancer surgery had significantly lower risks of surgical organ infection (OR, 0.35; 95% CI, 0.16-0.77; p = 0.009) and wound infection (OR, 0.19; 95% CI, 0.13-0.28; p < 0.001) compared to those undergoing open surgery. There was no heterogeneity observed between the two groups (I2  = 0) in wound infection. Nevertheless, because of the limited number of randomised controlled trials in this meta-analysis, care should be taken and carefully considered in the treatment of these values. Further high-quality studies involving a large number of samples are needed to validate and reinforce the results.

Operative and Hepatic Function Outcomes of Laparoscopic vs. Open Liver Resection: A Systematic Review and Meta-Analysis

Liver resection is a pivotal treatment for various liver diseases, and the choice between laparoscopic (LR) and open (OR) methods is debatable. This study aims to compare their respective complications and hepatic outcomes comprehensively, providing critical insights to guide clinical decisions and optimize patient results. We conducted a comprehensive review across PubMed, SCOPUS, WOS, and the Cochrane Library until September 2023. Randomized controlled trials (RCTs) comparing laparoscopic (LR) and open (OR) liver resections were included. Data screening, extraction, and quality assessments utilized the Risk of Bias (ROB-2). We conducted our analysis using Review Manager (RevMan 5.4) software, and the data were presented as risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI). Our comprehensive research yielded 3,192 relevant records, and 9 RCTs were finally included. LR exhibited reduced operative bleeding (MD = -82.87 ml, 95% CI: -132.45 to -33.30, P=0.001) and shorter hospital stays (MD = -2.32 days, 95% CI: -3.65 to -0.98, P=0.0007). The risk of complications was significantly lower in the LR group (RR = 0.57, 95% CI: 0.43-0.76, P<0.0001), especially in Clavian-Dindo classification degree 1 and 2 complications (RR = 0.47, 95% CI: 0.28-0.79, P=0.005). LR patients also had lower postoperative AST levels at one day (MD = -123.16 U/L, 95% CI: -206.08 to -40.24, P=0.004) and three days (MD = -35.95 U/L, 95% CI: -65.83 to -6.06, P=0.02). These findings underscore LR's superiority, emphasizing its potential to significantly enhance patient outcomes, reduce complications, and improve recovery in liver resection procedures.

Outcomes and Patient Selection in Laparoscopic vs. Open Liver Resection for HCC and Colorectal Cancer Liver Metastasis

Hepatocellular carcinoma (HCC) and colorectal liver metastasis (CRLM) are the two most common malignant tumors that require liver resection. While liver transplantation is the best treatment for HCC, organ shortages and high costs limit the availability of this option for many patients and make resection the mainstay of treatment. For patients with CRLM, surgical resection with negative margins is the only potentially curative option. Over the last two decades, laparoscopic liver resection (LLR) has been increasingly adopted for the resection of a variety of tumors and was found to have similar long-term outcomes compared to open liver resection (OLR) while offering the benefits of improved short-term outcomes. In this review, we discuss the current literature on the outcomes of LLR vs. OLR for patients with HCC and CRLM. Although the use of LLR for HCC and CRLM is increasing, it is not appropriate for all patients. We describe an approach to selecting patients best-suited for LLR. The four common difficulty-scoring systems for LLR are summarized. Additionally, we review the current evidence behind the emerging robotically assisted liver resection technology.

Perioperative and long-term survival outcomes of laparoscopic versus laparotomic hepatectomy for BCLC stages 0-A hepatocellular carcinoma patients associated with or without microvascular invasion: a multicenter, propensity score matching analysis

PURPOSE

To analyze the long-term oncological outcomes of Barcelona Clinic Liver Cancer (BCLC) stages 0-A hepatocellular carcinoma (HCC) patients associated with or without microvascular invasion (MVI) treated with laparoscopic versus laparotomic liver resection.

METHODS

Clinicopathological data of HCC patients with BCLC stages 0-A from four medical centers were retrospectively reviewed. The survival outcomes of patients who underwent laparoscopic hepatectomy were compared with those who underwent laparotomic hepatectomy. Subgroup analyses in terms of MVI were further performed to explore the effect of surgical approaches on the long-term survival outcomes. Propensity score matching (PSM) analysis was used to match patients between the laparoscopic and laparotomic resection groups in a 1:1 ratio.

RESULTS

495 HCC patients at BCLC stages 0-A were enrolled, including 243 in the laparoscopic resection group and 252 in the laparotomic resection group. Laparoscopic resection group had a shorter operation time, less blood loss, a lower frequency of blood transfusion and postoperative complication rates. The laparoscopic resection group had a significantly better overall survival (OS) and recurrence-free survival (RFS) than the laparotomic resection group before and after PSM. Subgroup analysis demonstrated that OS and RFS of patients without MVI were remarkably better in the laparoscopic resection group compared with the laparotomic resection group. However, no significant differences in OS and RFS between the two groups were found in patients with MVI after PSM.

CONCLUSIONS

Pure laparoscopic hepatectomy for patients with BCLC stages 0-A HCC can be performed safely with favorable perioperative and long-term oncological outcomes at high-volume liver cancer centers, regardless of the presence of MVI.

Impact of Three-Dimensional (3D) Visualization on Laparoscopic Hepatectomy for Hepatocellular Carcinoma

BACKGROUND

The impact of three-dimensional (3D) visualization on laparoscopic hepatectomy for hepatocellular carcinoma is largely unknown.

METHODS

A retrospective review with propensity-score matched analysis of 3D and two-dimensional (2D) laparoscopic hepatectomy performed in a tertiary hepatobiliary surgery center.

RESULTS

Since the availability of 3D laparoscopy, the proportion of laparoscopic major hepatectomies has significantly expanded (1.7% vs. 24.0%, p < 0.0001) and the percentage of difficult resections among patients who underwent laparoscopic hepatectomy has also increased (12.6% vs. 40.0%, p = 0.0001). A total of 305 patients (92 in the 3D group and 213 in the 2D group) underwent laparoscopic hepatectomy between 2002 and 2019. The 3D group had better liver function, larger tumors at more difficult locations, more major resections, and more difficult surgeries. After propensity score matching, 144 patients were analyzed (72 in both the 3D and 2D groups). Patients were comparable in terms of liver status, tumor status, and complexity of liver surgery. Operative time (218 vs. 218 mins, p = 0.50) and blood loss (0.2 vs. 0.2L, p = 0.49) were comparable between the two groups, however overall complications were higher in the 2D group (1.4 vs. 11.1%, p = 0.03). Patients who underwent 3D laparoscopic major hepatectomy had a shorter hospital stay than their comparable counterparts operated through an open approach (7 vs. 6 days, p = 0.003).

CONCLUSIONS

3D visualization enhanced the feasibility of laparoscopic major hepatectomy and difficult laparoscopic liver resection. 3D resection was potentially associated with fewer operative morbidities and the 3D laparoscopic approach did not jeopardize the outcome of major hepatectomy.

Robot-Assisted Liver Resection and Cholecystectomy Using Indocyanine-Green for Intrahepatic Cholangiocarcinoma, in a Very Rare Anatomical Anomaly of ‘Bipartite Liver’

Robotic hepatobiliary surgery has significantly developed worldwide with substantial clinical results. Hepatobiliary anatomical anomalies increase the complexity of hepatobiliary resection with a relevant risk of iatrogenic lesions. Among congenital liver anomalies, the ‘bipartite liver’ is an extremely rare condition which might be associated with complex surgical dissection of the hepatic hilum. We herein report a rare case of congenital ‘bipartite liver’ associated with a cholangiocarcinoma of segment VI and calculous cholecystitis. The patient underwent robot-assisted segmentectomy and cholecystectomy with the use of indocyanine-green cholangiography and intraoperative ultrasound. A challenging hilar dissection was performed using this approach. To the best of our knowledge, this is the first case reported that describes a robot-assisted liver resection and cholecystectomy in a patient having a cholangiocarcinoma associated with this rare liver anomaly. The robotic approach was safe and effective and the 3D preoperative imaging, as well as the intraoperative green-indocyanine cholangiography was extremely useful, especially during hilar dissection and cholecystectomy.

Current status of laparoscopic hepatectomy for the treatment of hepatocellular carcinoma: A systematic literature review

BACKGROUND

Laparoscopic hepatectomy (LH) was first introduced in the 1990s and has now become widely accepted for the treatment of hepatocellular carcinoma (HCC). Laparoscopic liver resection (LLR) is considered a safe and effective approach for liver disease. However, the role of laparoscopic hepatectomy in HCC with cirrhosis remains controversial and needs to be further assessed, and the present literature review aimed to review the surgical and oncological outcomes of Laparoscopic hepatectomy (LH). According to Hong and colleagues laparoscopic resection for liver cirrhosis is a very safe and feasible procedure for both ideal cases and select patients with high risk factors [29]. The presence of only 1 of these factors does not represent an absolute contraindication for LH.

METHODS AND RESULTS

We selected 23 studies involving about 1363 HCC patients treated with LH. 364 (27%) patients experienced major resections. The mean operative time was 244.9 minutes, the mean blood loss was 308.1 mL and blood transfusions were required in only 4.9% of patients. There were only 2 (0.21%) postoperative deaths and overall morbidity was 9.9%. Tumor recurrence ranged from 6 to 25 months. The 1-year, 3-year, and 5-year disease free Survival (DFS) rates ranged from 71.9% to 99%, 50.3% to 91.2%, and 19% to 82% respectively. Overall survival rates ranged from 88% to 100%, 73.4% to 94.5%, and 52.6% to 94.5% respectively.

CONCLUSIONS

In our summery LH is lower risk and safer than conventional open liver surgery and is just as efficacious. Also, the LH approach decreased blood-loss, operation time, postoperative morbidity and had a lower conversion rate compared to other procedures whether open or robotic. Finally, LH may serve as a promising alternative to open procedures.

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.

Clinical Study on the Efficacy of Laparoscopic Hepatectomy and Its Influence on the Expression of Serum VEGF, FGF, and Immune Function

Liver cancer is one of the most common malignant tumors. Partial hepatectomy is the most basic and effective treatment for hepatocellular carcinoma because of its high operative effect and perioperative safety. Open surgery is the most traditional hepatectomy. Although it can completely remove tumor lesions and prolong patient survival, it has disadvantages such as large trauma and long postoperative recovery time. Meanwhile, long-term bed rest can increase the risk of complications such as venous thrombosis and infection. The advantages of laparoscopic partial hepatectomy, such as clear operative field, simple operation, little trauma, light surgical stress, quick postoperative recovery, and low complications, can avoid damage to vital organs, blood vessels, and nerves, which has been widely accepted and recognized in clinical practice.

Laparoscopic Liver Surgery: What Are the Advantages in Patients with Cirrhosis and Portal Hypertension? Systematic Review and Meta-Analysis with Personal Experience

Background: Laparoscopic surgery is a choice of treatment for liver diseases; it can decrease postoperative morbidity and length of hospital stay (LOS). Hepatocellular carcinoma (HCC) in patients with cirrhosis and portal hypertension may benefit from minimally invasive liver resections (MILRs) instead of open liver resections (OLRs). Whether minimally invasive approaches are superior to conventional ones is still a matter of debate. We thus aimed to gather the available literature on this specific topic to achieve greater clarity. Materials and Methods: PubMed, EMBASE and Web of Sciences databases were assessed for studies comparing OLRs versus MILRs for HCC in cirrhotic patients up to February 2020. Data from our surgical experience from June 2010 to February 2020 were also included. Demographic characteristics, liver function, the presence of portal hypertension, tumor number, and tumor size and location were assessed; operative time, need for Pringle maneuver, estimated blood loss (EBL), major or minor hepatectomy performance, and conversion rate were evaluated for operative findings. Postoperative outcomes and liver-related complications, surgical site infection (SSI) rate, blood transfusion (BT) rate, need for reintervention, LOS, in-hospital or 30-day mortality, and radicality of resection were also considered. Meta-analysis was performed employing Review Manager 5.3 software. Results: One thousand three hundred twenty-one patients from 13 studies and our own series were considered in the meta-analysis. At preoperative settings, the OLR and MILR groups differed significantly only by tumor size (4.4 versus 3.0, P = .006). Laparoscopic procedures resulted significantly faster (120.32-330 minutes versus 146.8-342.75 minutes, P = .002) and with lower EBL than open ones (88-483 mL versus 200-580 mL, P < .00001), thus requiring less BTs (7.9% versus 13.2%, P = .02). In terms of overall morbidity, minimally invasive surgeries resulted significantly favorable (19.32% versus 38.04%, P < .00001), as well as for ascites (2.7% versus 12.9% P < .00001), postoperative liver failure (7.51% versus 13.61% P = .009), and SSI (1.8% versus 5.42%, P = .002). Accordingly, patients who had undergone MILRs had significantly shorter postoperative hospitalization than patients who underwent conventional open surgery (2.4-36 days versus 4.2-19 days P < .00001). Both groups did not differ in terms of mortality rate and radicality of resection (OLR 93.8% versus 96.1% laparoscopic liver resection, P = .12). Conclusions: Based on the available evidence in the literature, laparoscopic resections rather than open liver ones for HCC surgery in cirrhotic patients seem to reduce postoperative overall morbidity, liver-specific complications, and LOS. The lack of randomized studies on this topic precludes the possibility of achieving defining statements.

Laparoscopic liver resection: indications, limitations, and economic aspects

Background

Minimally invasive techniques have increasingly found their way into liver surgery in recent years. A multitude of mostly retrospective analyses suggests several advantages of laparoscopic over open liver surgery. Due to the speed and variety of simultaneous technical and strategic developments, it is difficult to maintain an overview of the current status and perspectives in laparoscopic liver surgery.

Purpose

This review highlights up-to-date aspects in laparoscopic liver surgery. We discuss established indications with regard to their development over time as well as continuing limitations of applied techniques. We give an assessment based on the current literature and according to our own center experiences, not least with regard to a highly topical cost discussion.

Conclusions

While in the beginning mainly benign tumors were laparoscopically operated on, liver metastasis and hepatocellular carcinoma are now among the most frequent indications. Technical limitations remain and should be evaluated with the overall aim not to endanger quality standards in open surgery. Financial aspects cannot be neglected with the necessity of cost-covering reimbursement.

Appraisal of disease-specific benefits of minimally invasiveness in surgery of breast cancer liver metastases

BACKGROUND

The primary endpoint of this study is to analyze short term benefit of laparoscopic approach (minimally invasive liver surgery [MILS]) over the open techniques in patients submitted to surgery for breast cancer liver metastases (BCLM) within a disease-specific perspective.

MATERIAL AND METHODS

A group of 30 patients who underwent laparoscopic liver resection for BCLM constituted the Study group (MILS group) and was matched in a ratio of 1:2 with patients who underwent open surgery for BCLM (Open group, constituting the Control group).

RESULTS

MILS approach resulted in a statistically significant lower blood loss (150 vs 300 mL; P < .05). The rate of postoperative complications was similar (13.3% and 16.6% in the MILS and Open groups, respectively). MILS approach was associated with a shorter length of postoperative stay (4 ± 2 days) compared with the Open group (7 ± 3 days), allowing a faster return to adjuvant treatments. Both MILS and open groups showed adequate oncological radicality, with comparable long-term results.

CONCLUSION

MILS approach to BCLM represents the optimal instrument to obtain an adequate disease clearance in the selected group of patients candidates to surgery: the type of procedure (minor resections for limited hepatic disease) and characteristics of patients contribute to enhance the feasibility and the benefits of the laparoscopic technique.

Early Morbidity and Mortality after Minimally Invasive Liver Resection for Hepatocellular Carcinoma: a Propensity-Score Matched Comparison with Open Resection

BACKGROUND

The impact of minimally invasive surgery on the short-term outcomes of patients with hepatocellular carcinoma (HCC) undergoing liver resection remains poorly defined.

METHODS

The ACS-NSQIP-targeted hepatectomy database was used to identify patients who underwent liver resection for HCC during 2014-2016. A 1:1 propensity score matching was created between patients who underwent open (OLR) vs. minimally invasive liver resection (MILR) based on age, ASA score, liver resection type, liver texture, and stage of disease. The short-term outcomes of patients undergoing OLR vs. MILR were compared.

RESULTS

Among a total cohort of 1816 patients, propensity score matching resulted in 728 liver resections: 364 (50%) OLR and 364 (50%) MILR. Overall morbidity (29% vs. 23%, P = 0.04) was greater among patients undergoing OLR compared with MILR, whereas mortality did not differ between the two approaches (2% vs 1%, P = 0.57). MILR was associated with significant reductions in hospital LOS (6 vs. 4 days, P < 0.0001) but no difference in operative time (188 vs. 171 min, P = 0.13). On multivariate logistic regression analysis, age ≥ 65 (OR:1.6, 95%CI: 1.1-2.3, P = 0.0065), ASA class ≥ 3 (OR:2.7, 95%CI: 1.5-4.7, P = 0.0003), preoperative blood transfusion (OR:9.7, 95%CI: 1.06-90.3, P = 0.04), T ≥ 3 (OR:1.9, 95%CI: 1.09-3.4, P = 0.02), operative time > 200 min (OR:1.8, 95%CI: 1.2-2.5, P = 0.0011), and OLR (OR:1.4, 95%CI: 1.002-2.03, P = 0.04) were associated with increased odds of overall morbidity.

CONCLUSIONS

MILR for HCC is associated with a shorter hospital LOS and reduced postoperative complication rates, even after controlling for important patient and clinicopathologic confounders, compared to OLR. Efforts to expand the use of MILR for hepatobiliary surgery are warranted.

A Systematic Review and Meta-Analysis Comparing the Short- and Long-Term Outcomes for Laparoscopic and Open Liver Resections for Hepatocellular Carcinoma: Updated Results from the European Guidelines Meeting on Laparoscopic Liver Surgery, Southampton, UK, 2017

BACKGROUND

The laparoscopic approach to liver resection has experienced exponential growth in recent years; however, its application is still under debate and objective, evidence-based guidelines for its safe future progression are needed.

OBJECTIVE

The aim of this study was to perform a systematic review and meta-analysis comparing the short- and long-term outcomes of laparoscopic and open liver resections for hepatocellular carcinoma (HCC).

METHODS

To identify all the comparative manuscripts reporting on laparoscopic and open liver resection for HCC, all published English-language studies with more than 10 cases were screened. In addition to the primary meta-analysis, four specific subgroup analyses were performed on patients with Child-Pugh A cirrhosis, resections for solitary tumors, and those undergoing minor and major resections. The quality of the studies was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) methodology and the Newcastle-Ottawa Scale.

RESULTS

From the initial 361 manuscripts, 28 were included in the meta-analysis. Five of these 28 manuscripts were specific to patients with Child-Pugh A cirrhosis (321 cases), 11 focused on solitary tumors (1003 cases), 16 focused on minor resections (1286 cases), and 3 focused on major resections (164 cases). Three manuscripts compared 1079 cases but could not be assigned to any of the above subanalyses. In general terms, short-term outcomes were favorable when using a laparoscopic approach, especially in minor resections. The only advantage seen with an open approach was reduced operative time during major liver resections. No differences in long-term outcomes were observed between the approaches.

CONCLUSIONS

Laparoscopic liver resection for HCC is feasible and offers improved short-term outcomes, with comparable long-term outcomes as the open approach.

The current role of laparoscopic resection for HCC: a systematic review of past ten years

The use of laparoscopic liver resection (LLR) has progressively spread in the last 10 years. Several studies have shown the superiority of LLR to open liver resection (OLR) in term of perioperative outcomes. With this review, we aim to systematically assess short-term and long-term major outcomes in patients who underwent LLR for hepatocellular carcinoma (HCC) in order to illustrate the advantages of minimally invasive liver surgery. Through an advanced PubMed research, we selected all retrospective, prospective, and comparative clinical trials reporting short-term and long-term outcomes of any series of patients with diagnosis of HCC who underwent laparoscopic or robotic resection. Reviews, meta-analyses, or case reports were excluded. None of the patients included in this review has received a previous locoregional treatment for the same tumor nor has undergone a laparoscopic-assisted procedure. We considered morbidity and mortality for evaluation of major short-term outcomes, and overall survival (OS) and disease-free survival (DFS) for evaluation of long-term outcomes. A total of 1,501 patients from 17 retrospective studies were included, 15 studies compare LLR with OLR. Propensity-score matching (PSM) analysis was used in 11 studies (975 patients). The majority of the studies included patients with good liver function and a single HCC. Cirrhosis at pathology ranged from 33% to 100%. Overall mortality and morbidity ranges were 0-2.4% and 4.9-44% respectively, with most of the complications being Clavien-Dindo grade I or II (range: 3.9-23.3% vs. 0-9.52% for Clavien I-II and ≥ III respectively). The median blood loss ranged from 150 to 389 mL; the range of the median duration of surgery was 134-343 minutes. The maximum rate of conversion was 18.2%. The median duration of hospitalization ranged from 4 to 13 days. The ranges of overall survival rates at 1-, 3- and 5-year were 72.8-100%, 60.7-93.5% and 38-89.7% respectively. The ranges of disease free survival rates at 1-, 3- and 5-year were 45.5-91.5%, 20-72.2% and 19-67.8% respectively. The benefits of LLR in term of complication rate, blood loss, and duration of hospital stay make this procedure an advantageous alternative to OLR, especially for cirrhotic patients in whom the use of LLR reduces the risk of post-hepatectomy liver failure. The limits of LLR can be overcome by robotic surgery, which could therefore be preferred. Further benefits of minimally invasive surgery derive from its ability to reduce the formation of adhesions in view of a salvage liver transplant. In conclusion, the results of this review seem to confirm the safety and feasibility of LLR for HCC as well as its superiority to OLR according to perioperative 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.

Minimally invasive donor hepatectomy, are we ready for prime time?

Minimally invasive surgery potentially reduces operative morbidities. However, pure laparoscopic approaches to donor hepatectomy have been limited by technical complexity and concerns over donor safety. Reduced-wound donor hepatectomy, either in the form of a laparoscopic-assisted technique or by utilizing a mini-laparotomy wound, i.e., hybrid approach, has been developed to bridge the transition to pure laparoscopic donor hepatectomy, offering some advantages of minimally invasive surgery. To date, pure laparoscopic donor left lateral sectionectomy has been validated for its safety and advantages and has become the standard in experienced centres. Pure laparoscopic approaches to major left and right liver donation have been reported for their technical feasibility in expert hands. Robotic-assisted donor hepatectomy also appears to be a valuable alternative to pure laparoscopic donor hepatectomy, providing additional ergonomic advantages to the surgeon. Existing reports derive from centres with tremendous experience in both laparoscopic hepatectomy and donor hepatectomy. The complexity of these procedures means an arduous transition from technical feasibility to reproducibility. Donor safety is paramount in living donor liver transplantation. Careful donor selection and adopting standardized techniques allow experienced transplant surgeons to safely accumulate experience and acquire proficiency. An international prospective registry will advance the understanding for the role and safety of pure laparoscopic donor hepatectomy.

A Sling Technique for Laparoscopic Resection of Segment Seven of the Liver

Introduction:

As the incidence of liver cancer continues to increase in the setting of cirrhosis, parenchyma-sparing liver resection is increasingly necessary. A technique is described that involves using a sling made from 1-inch-wide packing gauze to retract and rotate the liver to divide the right triangular and coronary ligaments and mobilize segment 7. The right lobe is rotated anteriorly and counterclockwise, allowing access and parenchymal transection of segment 7 under ultrasonographic guidance.

Case Presentation:

Seven patients with tumors in segment 7 underwent resection with the technique described above: 4 had Child's A cirrhosis and hepatocellular carcinoma (HCC), 1 had metastatic colon cancer, 1 had an adenoma, and 1 had a symptomatic hemangioma. Tumor size ranged between 2.5 and 7.7 cm. Blood loss during resection was between 150 and 500 mL. No patients required transfusion as a result of surgery. With the exception of 1 patient with Clostridium difficile colitis, the average hospital stay was 3.8 days.

Management and Outcome:

Parenchyma-sparing laparoscopic resection of segment 7 is feasible and can be safely performed using a sling for intracorporal hepatic retraction, manipulation, and positioning. Given the risk of HCC recurrence, laparoscopic liver resection may also be better suited for subsequent salvage liver transplant because of less perihepatic adhesions.

Surgical Resection vs. Ablative Therapies Through a Laparoscopic Approach for Hepatocellular Carcinoma: a Comparative Study

BACKGROUND

When compatible with the liver functional reserve, laparoscopic hepatic resection remains the treatment of choice for hepatocellular carcinoma while laparoscopic ablation therapies appear as a promising less invasive alternative. The aim of the study is to compare two homogeneous groups of patients submitted to either hepatic resection or thermoablation for the treatment of single hepatocellular carcinoma (≤ 3 cm).

METHODS

We enrolled 264 cirrhotic patients out of 905 cases consecutively evaluated for hepatocellular carcinoma. We performed 59 hepatic resections and 205 thermoablations through a laparoscopic approach, and they were then followed for similar follow-up (41.7 ± 31.5 months for laparoscopic hepatic resection vs. 38.7±32.3 for laparoscopic ablation therapy). Outcomes included short- and long-term morbidities, tumoral recurrence, and overall survival.

RESULTS

Short-term morbidity was significantly higher in the resection group (but the two groups had similar rates for severe complications) while, during follow-up, recurrence was more frequent in patients treated with thermoablation, with a clear disadvantage in terms of survival. At multivariate analysis, only the type of surgical treatment was an independent predictor of disease recurrence, while plasmatic alpha-fetoprotein and Hb values, model for end-stage liver disease score, time to recurrence, and the type of surgical treatment were independent predictors of overall survival.

CONCLUSION

Our data ultimately support some therapeutic advantages for hepatic resection in patients with a single nodule and preserved liver function. However, thermoablation is an adequate alternative in patients with nodules that would require complex surgical resections or imply a poor prognosis that might therefore better tolerate a less invasive procedure.

Laparoscopic versus Open Surgery for Hepatocellular Carcinoma: A Meta-Analysis of High-Quality Case-Matched Studies

OBJECTIVE

To present a meta-analysis of high-quality case-matched studies comparing laparoscopic (LH) and open hepatectomy (OH) for hepatocellular carcinoma (HCC).

METHODS

Studies published up to September 2017 comparing LH and OH for HCC were identified. Selection of high-quality, nonrandomized comparative studies (NRCTs) with case-matched design was based on a validated tool (Methodological Index for Nonrandomized Studies) since no randomized controlled trials (RCTs) were published. Morbidity, mortality, operation time, blood loss, hospital stay, margin distance, recurrence, and survival outcomes were compared. Subgroup analyses were carried out according to the surgical extension (minor or major hepatectomy).

RESULTS

Twenty studies with a total of 830 patients (388 in LH and 442 in OH) were identified. For short-term surgical outcomes, LH showed less morbidity (RR = 0.55; 95% CI, 0.47~0.65; P < 0.01), less mortality (RR = 0.43; 95% CI, 0.18~1.00; P = 0.05), less blood loss (WMD = -93.21 ml, 95% CI, -157.33~-29.09 ml; P < 0.01), shorter hospital stay (WMD = -2.86, 95% CI, -3.63~-2.08; P < 0.01), and comparable operation time (WMD = 9.15 min; 95% CI: -7.61~25.90, P = 0.28). As to oncological outcomes, 5-year overall survival rate was slightly better in LH than OH (HR = 0.66, 95% CI: 0.52~0.84, P < 0.01), whereas the 5-year disease-free survival rate was comparable between two groups (HR = 0.88, 95% CI: 0.74~1.06, P = 0.18).

CONCLUSION

This meta-analysis has highlighted that LH can be safely performed in selective patients and improves surgical outcomes as compared to OH. Given the limitations of study design, especially the limited cases of major hepatectomy, methodologically high-quality comparative studies are needed for further evaluation.

Current topics in the surgical treatments for hepatocellular carcinoma

Treatment strategy for hepatocellular carcinoma (HCC) requires optimal selection of therapies based on various factors related to tumor condition and liver functional reserve. Although several evidence-based guidelines have been proposed for the treatment of HCC, the criteria and range of indications differ among these guidelines according to the circumstances of each country. In European nations and the USA, patients with the Barcelona Clinic Liver Cancer stage 0-A are subjects for surgical resection, whereas in Asian countries, even those with the intermediate stage are regarded as surgical candidates. Furthermore, since the recent introduction and rapidly widely spreading use of laparoscopic liver resection, this technique has become an important treatment option for surgical resection. In this review article, we overview the current topics of treatment of HCC with a special focus on surgical therapy.

Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations

BACKGROUND

Enhanced Recovery After Surgery (ERAS) is a multimodal pathway developed to overcome the deleterious effect of perioperative stress after major surgery. In colorectal surgery, ERAS pathways reduced perioperative morbidity, hospital stay and costs. Similar concept should be applied for liver surgery. This study presents the specific ERAS Society recommendations for liver surgery based on the best available evidence and on expert consensus.

METHODS

A systematic review was performed on ERAS for liver surgery by searching EMBASE and Medline. Five independent reviewers selected relevant articles. Quality of randomized trials was assessed according to the Jadad score and CONSORT statement. The level of evidence for each item was determined using the GRADE system. The Delphi method was used to validate the final recommendations.

RESULTS

A total of 157 full texts were screened. Thirty-seven articles were included in the systematic review, and 16 of the 23 standard ERAS items were studied specifically for liver surgery. Consensus was reached among experts after 3 rounds. Prophylactic nasogastric intubation and prophylactic abdominal drainage should be omitted. The use of postoperative oral laxatives and minimally invasive surgery results in a quicker bowel recovery and shorter hospital stay. Goal-directed fluid therapy with maintenance of a low intraoperative central venous pressure induces faster recovery. Early oral intake and mobilization are recommended. There is no evidence to prefer epidural to other types of analgesia.

CONCLUSIONS

The current ERAS recommendations were elaborated based on the best available evidence and endorsed by the Delphi method. Nevertheless, prospective studies need to confirm the clinical use of the suggested protocol.

Meta-analysis of laparoscopic vs open liver resection for hepatocellular carcinoma

Laparoscopic liver resections (LLR) are widely accepted as safe and effective procedures for the management of hepatocellular carcinoma (HCC) in the hands of experienced surgeons. The efficacy and extent of benefits of pure as well as hand-assisted laparoscopic and laparoscopy-assisted liver resection over open liver resection (OLR) have been investigated by numerous studies during the last 10 years. The aim of our meta-analysis is to investigate the effect of LLR in short- and long-term outcomes compared to OLR in patients operated for HCC. A total of 5203 patients from forty-four studies were included in our meta-analysis reporting for short- and long-term results for both LLR and OLR for HCC. Among them, 1830 underwent pure laparoscopic hepatectomy, 282 underwent pure laparoscopic or hand-assisted laparoscopic or laparoscopy-assisted hepatectomy, and 3091 were operated through open approach. LLRs were found to be significantly associated with lower blood loss, need for blood transfusion, successful achievement of R0 resection as well as wider resection margin, shorter hospital stay, lower morbidity and 30-day mortality rates. Operative time, tumor recurrence, 1-, 3-, and 5-year overall survival as well as 1-, 3-, and 5-year disease-free survival were not found different between the groups. This meta-analysis clearly demonstrates the superiority of laparoscopic resection over the open approach for patients with small HCC.

Impact of ERAS approach and minimally-invasive techniques on outcome of patients undergoing liver surgery for hepatocellular carcinoma

BACKGROUND AND AIM

Aim of the study was to assess the impact of ERAS approach ("fluid restrictive and drainless") on open liver resections for HCC comparing their outcome with open resections in pre-ERAS period and with laparoscopic surgery.

STUDY DESIGN

207 patients undergoing minor liver resection for HCC were divided into three groups: Group A, open minor resections in pre-ERAS period (95 patients); Group B, laparoscopic ERAS resections (55 patients); Group C, open ERAS resections (57 patients).

RESULTS

Blood loss was lower in group C and B compared with group A. Postoperative morbidity was 26.5% in group A, 16.3% in group B and 12.1% in group C (p<0.05). Ascites was less frequent in group B (7.5%) and C (6.2%) compared with group A (12%). Median time for functional recovery in group B (3 days) and C (3 days) was shorter compared with group A (5 days).

CONCLUSIONS

Laparoscopic approach confirms to be associated with reduced blood loss and postoperative morbidity. In patients who cannot be candidates to minimally-invasive approach, ERAS management seems to allow blood loss and postoperative morbidity reduction: indeed, results achieved in this group of patients are more similar to those of laparoscopy than to pre-ERAS open surgery.

IS RESECTION OF HEPATOCELLULAR CARCINOMA IN THE ERA OF LIVER TRANSPLANTATION WORTHWILE? A single center experience

ABSTRACT Background - Liver resection for hepatocellular carcinoma is a potentially curative therapeutic procedure that can be performed readily after its indication, without the need of a long waiting time and lower costs when compared to liver transplantation, being a good alternative in patients with preserved/good liver function. Objective - Evaluate long-term results of liver resection from a high volume single center for selected patients with hepatocellular carcinoma in a context of a long waiting list for liver transplant. Methods - One hundred and one patients with hepatocellular carcinoma, with a mean age of 63.1 years, and preserved liver function were submitted to liver resection. Clinical and pathological data were evaluated as prognostic factors. Mean follow-up was 39.3 months. Results - All patients had a single nodule and 57 (58.2%) patients were within the Milan criteria. The size of the nodule ranged from 1 to 24 cm in diameter. In 74 patients, liver resection was performed with the open approach and in 27 (26.7%) was done laparoscopically. Postoperative morbidity was 55.3% being 75.5% of the complications classified as Dindo-Clavien I and II and operative mortality was 6.9%. Five-year overall and disease free survival rates were 49.9% and 40.7%, respectively.After a log-rank univariate analysis, the levels of preoperative alpha-fetoprotein (P=0.043), CA19-9 (P=0.028), capsule invasion (P=0.03), positive margin (R1-R2) (P=0.004) and Dindo-Claviens' morbidity classification IV (P=0.001) were the only parameters that had a significant negative impact on overall survival. On the odds-ratio evaluation, the only significant factors for survival were high levels of alpha-fetoprotein (P=0.037), and absence of free margins (P=0.008). Conclusion - Resection, for selected cases, is a potentially curative treatment with acceptable morbidity and mortality and, in a context of a long waiting list for transplant, plays an important role for the treatment of hepatocellular carcinoma.

Effectiveness and safety of single-port versus multi-port laparoscopic surgery for treating liver diseases: a meta-analysis

OBJECTIVE

To compare the effectiveness and safety of single-port versus multi-port laparoscopic surgery for treating liver diseases.

METHODS

Several databases were systematically searched for randomized controlled trials, cohort studies, and case-control studies on the use of single-port versus multi-port laparoscopic surgery to treat liver diseases from their inception until March 24, 2016. The primary outcomes were the operative time, volume of intraoperative blood loss, rate of postoperative complications, median length of postoperative stay, recovery time of gastrointestinal function, volume of postoperative drainage, and postoperative drainage time. The study-specific effect sizes and their 95 % confidence interval were all combined to calculate the pooled value by using a random-effects model.

RESULTS

A total of nine studies were included, which involved 277 patients. The total and subgroup data were combined by meta-analysis. This meta-analysis showed that single-port and multi-port laparoscopic liver surgery for treating liver diseases did not differ in terms of operative time (P = 0.48), rate of postoperative complications (P = 0.56), median length of postoperative stay (P = 0.80), and recovery time of gastrointestinal function (P = 0.54). For liver diseases, the single-port group exhibited a lower volume of intraoperative blood loss than that presented by the multi-port group (P = 0.0006). In the hepatic resection subgroup, a lower volume of intraoperative blood loss was noted in the single-port group (P < 0.0001). By contrast, in the hepatic cyst subgroup, the single-port group showed a higher volume of intraoperative blood loss (P = 0.02) but a shorter median length of postoperative stay (P = 0.02). The findings of the potential subgroup analysis in these outcomes were consistent with the total data.

CONCLUSION

Compared with multi-port laparoscopic surgery, the single-port method showed comparable effectiveness and safety for the treatment of liver diseases in terms of current evidence.

Fast track program in liver resection: a PRISMA-compliant systematic review and meta-analysis

BACKGROUND

FT program (FT) is a multimodal approach used to enhance postoperative rehabilitation and accelerate recovery. It was 1st described in open heart surgery, then modified and applied successfully in colorectal surgery. FT program was described in liver resection for the 1st time in 2008. Although the program has become widely accepted, it has not yet been considered the standard of care in liver surgery.

OBJECTIVES

we performed this systematic review and meta-analysis to evaluate the impact of using the FT program compared to the traditional care (TC), on the main clinical and surgical outcomes for patients who underwent elective liver resection.

METHODS

PubMed/Medline, Scopus, and Cochran databases were searched to identify eligible articles that compared FT with TC in elective liver resection to be included in this study. Subgroup meta-analysis between laparoscopic and open surgical approaches to liver resection was also conducted. Quality assessment was performed for all the included studies. Odds ratios (ORs) and mean differences (MDs) were considered as a summary measure of evaluating the association in this meta-analysis for dichotomous and continuous data, respectively. A 95% confidence interval (CI) was reported for both measures. I was used to assess the heterogeneity across studies.

RESULTS

From 2008 to 2015, 3 randomized controlled trials (RCTs) and 5 cohort studies were identified, including 394 and 416 patients in the FT and TC groups, respectively. The length of hospital stay (LoS) was markedly shortened in both the open and laparoscopic approaches within the FT program (P < 0.00001). The reduced LoS was accompanied by accelerated functional recovery (P = 0.0008) and decreased hospital costs, with no increase in readmission, morbidity, or mortality rates. Moreover, significant results were found within the FT group such as reduced operative time (P = 0.03), lower intensive care unit admission rate (P < 0.00001), early bowel opening (P ≤ 0.00001), and rapid normal diet restoration (P ≤ 0.00001).

CONCLUSION

FT program is safe, feasible, and can be applied successfully in liver resection. Future RCTs on controversial issues such as multimodal analgesia and adherence rate are needed. Specific FT guidelines should be developed for liver resection.

Current status of laparoscopic liver resection for hepatocellular carcinoma

Laparoscopic liver resection (LLR) is becoming widely accepted for the treatment of hepatocellular carcinoma (HCC). Laparoscopic left lateral sectionectomy and minor laparoscopic liver resection are now considered standard approaches, especially for tumors located in the anterolateral segments of the liver. Laparoscopic left lateral sectionectomy in adult donors is also gaining acceptance for child liver transplantation in many centers. Major LLRs, including left hepatectomy and right hepatectomy, have been recently attempted. Laparoscopic donor hepatectomy is becoming more popular owing to increasing demand from young living donors who appreciate its minimal invasiveness and excellent cosmetic outcomes. Several centers have performed total laparoscopic donor right hepatectomy in adult-to-adult living donor liver transplantation. Many meta-analyses have shown that LLR is better than open liver resection in terms of short-term outcomes, principally cosmetic outcomes. Although no randomized control trials have compared LLR with open liver resection, the long-term oncologic outcomes were similar for both procedures in recent case-matched studies.

Management of hepatocellular carcinoma: an overview of major findings from meta-analyses

This paper aims to systematically review the major findings from meta-analyses comparing different treatment options for hepatocellular carcinoma (HCC). A total of 153 relevant papers were searched via the PubMed, EMBASE, and Cochrane library databases. They were classified according to the mainstay treatment modalities (i.e., liver transplantation, surgical resection, radiofrequency ablation, transarterial embolization or chemoembolization, sorafenib, and others). The primary outcome data, such as overall survival, diseases-free survival or recurrence-free survival, progression-free survival, and safety, were summarized. The recommendations and uncertainties regarding the treatment of HCC were also proposed.

Laparoscopic Right Hepatectomy for Cirrhotic Patients: Takasaki's Hilar Control and Caudal Approach

BACKGROUND

Cirrhotic patients bearing hepatocellular carcinomas (HCC) derive benefits from laparoscopic hepatectomy1 ^- 6 such as reduced bleeding, less overall and liver-specific complications, and fewer adhesions in the case of future reoperation or transplantation.7 ^- 10 Bleeding is concerning in the setting of cirrhosis,11 ^- 15 and adequate inflow control reduces blood loss. The caudal approach is the laparoscopic counterpart of the anterior approach to open surgery. It implies in parenchymal transection initiated from the visceral surface of the liver after limited hepatic mobilization, reducing the risk of increased circulating tumoral cells.16 ^- 18 Venous outflow transection and completion of ligament mobilization are left as last steps.

METHODS

A 46 years-old-male with hepatitis C virus and alcoholic cirrhosis was diagnosed with a 4-cm HCC (right hepatic lobe). Expected future liver remnant was 45 % of his total liver volume. A totally laparoscopic right hepatectomy was performed using six ports, and the specimen was removed through a Pfannenstiel auxiliary incision. A 10-mm 30° scope was used. The pneumoperitoneum pressure was set to 12 mmHg. The right hepatic pedicle, the caudate lobe, and the major hepatic veins were managed with laparoscopic vascular staplers.

RESULTS

Surgery was performed with limited liver mobilization and en bloc extrafascial right pedicle control (Takasaki's technique),19 followed by caudal parenchymal transection along the paracaval plane. The operative time was 450 min, and the estimated blood loss was 800 ml (no transfusion was required).

CONCLUSION

The laparoscopic Takasaki technique and caudal approach are feasible procedures in the setting of cirrhosis, resulting in an oncologic adequate intervention with less morbidity.

Progress in surgical and nonsurgical approaches for hepatocellular carcinoma treatment

BACKGROUND

Hepatocellular carcinoma (HCC) is a complex and heterogeneous malignancy, frequently occurs in the setting of a chronically diseased organ, with multiple confounding factors making its management challenging. HCC represents one of the leading causes of cancer-related mortality globally with a rising trend of incidence in some of the developed countries, which indicates the need for better surgical and nonsurgical management strategies.

DATA SOURCES

PubMed database was searched for relevant articles in English on the issue of HCC management.

RESULTS

Surgical resection represents a potentially curative option for appropriate candidates with tumors detected at earlier stages and with well-preserved liver function. The long-term outcome of surgery is impaired by a high rate of recurrence. Surgical approaches are being challenged by local ablative therapies such as radiofrequency ablation and microwave ablation in selected patients. Liver transplantation offers potential cure for HCC and also correction of underlying liver disease, and minimizes the risk of recurrence, but is reserved for patients within a set of criteria proposed for a prudent allocation in the shortage of donor organs. Transcatheter locoregional therapies have become the palliative standard allowing local control for intermediate stage patients with noninvasive multinodular or large HCC who are beyond the potentially curative options. The significant survival benefit with the multikinase inhibitor sorafenib for advanced HCC has shifted the direction of research regarding systemic treatment toward molecular therapies targeting the disregulated pathways of hepatocarcinogenesis. Potential benefit is suggested from simultaneous or sequential multimodal therapies, and optimal combinations are being investigated. Despite the striking progress in preclinical studies of HCC immunotherapy and gene therapy, extensive clinical trials are required to achieve successful clinical applications of these innovative approaches.

CONCLUSION

Treatment decisions have become increasingly complex for HCC with the availability of multiple surgical and nonsurgical therapeutic options and require a comprehensive, multidisciplinary approach.

Favorable Long-Term Oncologic Outcomes of Hepatocellular Carcinoma Following Laparoscopic Liver Resection

BACKGROUND

Reports on the long-term oncologic outcomes of laparoscopic liver resection (LLR) compared to open liver resection (OLR) in patients with hepatocellular carcinoma (HCC) are rare. The aim of this study was to compare the long-term outcomes of LLR and OLR as a treatment for HCC patients.

PATIENTS AND METHODS

A total of 125 patients were included in the study (32 patients underwent LLR and 93 underwent OLR). Data were categorized according to operation methods. The primary endpoints were disease-free survival and overall survival. The secondary endpoints were surgical outcomes of LLR for HCC.

RESULTS

Capsular invasion was more frequent in the LLR group (P = .001). The median follow-up period was 48 months (1-188 month). There were no significant differences between the two groups regarding mortality and morbidity. Hospitalization days were shorter in the LLR group (P = .042). Disease-free 5-year survival of HCC was 40.9% and 47.2% in the LLR and OLR group, respectively (P = .376). Overall 5-year survival for HCC was 96.4% and 96.7% for the LLR and OLR group, respectively (P = .748).

CONCLUSION

Our long-term analysis on oncologic aspects confirms the safety of LLR compared to OLR in HCC patients.

Intraoperative monitoring of stroke volume variation versus central venous pressure in laparoscopic liver surgery: a randomized prospective comparative trial

BACKGROUND

Central venous pressure (CVP) is used as a marker of cardiac preload to control intraoperative blood loss in open hepatectomies, while its reliability in laparoscopy is less certain. The aim of this randomized prospective trial was to evaluate the outcome of laparoscopic resections performed with stroke volume variation (SVV) or CVP monitoring.

METHODS

All candidates for laparoscopic liver resection were assigned randomly to SVV or to CVP groups. Outcome was evaluated included conversion rate, cause of conversion, intraoperative blood loss, need for transfusions, length of surgery and postoperative results.

RESULTS

Ninety consecutive patients were enrolled: both SVV and CVP groups included 45 patients each and were comparable in terms of patient and disease characteristics. A reduced rate of conversion was recorded in the SVV compared to the CVP group (6.7% and 17.8% respectively, p = 0.02). Blood loss was lower in the SVV group (150 mL), compared to the CVP group (300 mL, p = 0.04). Morbidity, mortality, length of stay and functional recovery were comparable. On multivariate analysis, lesion location, extent of hepatectomy and type of cardiac preload monitoring were associated significantly to risk of conversion.

CONCLUSION

SVV monitoring in laparoscopic liver surgery improves intraoperative outcome, thus enhancing the benefits of the minimally-invasive approach and fast-track protocols.

Laparoscopic liver resection: Experience based guidelines

Laparoscopic liver resection (LLR) has been progressively developed along the past two decades. Despite initial skepticism, improved operative results made laparoscopic approach incorporated to surgical practice and operations increased in frequency and complexity. Evidence supporting LLR comes from case-series, comparative studies and meta-analysis. Despite lack of level 1 evidence, the body of literature is stronger and existing data confirms the safety, feasibility and benefits of laparoscopic approach when compared to open resection. Indications for LLR do not differ from those for open surgery. They include benign and malignant (both primary and metastatic) tumors and living donor liver harvesting. Currently, resection of lesions located on anterolateral segments and left lateral sectionectomy are performed systematically by laparoscopy in hepatobiliary specialized centers. Resection of lesions located on posterosuperior segments (1, 4a, 7, 8) and major liver resections were shown to be feasible but remain technically demanding procedures, which should be reserved to experienced surgeons. Hand-assisted and laparoscopy-assisted procedures appeared to increase the indications of minimally invasive liver surgery and are useful strategies applied to difficult and major resections. LLR proved to be safe for malignant lesions and offers some short-term advantages over open resection. Oncological results including resection margin status and long-term survival were not inferior to open resection. At present, surgical community expects high quality studies to base the already perceived better outcomes achieved by laparoscopy in major centers’ practice. Continuous surgical training, as well as new technologies should augment the application of laparoscopic liver surgery. Future applicability of new technologies such as robot assistance and image-guided surgery is still under investigation.

Laparoscopic liver resection for hepatocellular carcinoma in patients with cirrhosis

Liver resection for patients with cirrhosis remains a challenging operation. The presence of thrombocytopenia and portal hypertension could lead to severe bleeding during hepatectomy. The enthusiasm of laparoscopic hepatectomy has been growing and many studies have reported their initial favorable results for patients with hepatocellular carcinoma (HCC). The advancement in technology, better understanding of the use of pneumoperitoneum pressure and more experience accumulated make laparoscopic liver resection for patients with cirrhosis possible. Favorable outcome may be achieved if the patients are carefully selected and carried out in high volume centers.

Laparoscopic right hepatectomy for hepatocellular carcinoma in cirrhotic patient

Hepatocellular carcinoma (HCC) is the sixth most common malignant tumor worldwide and the most common primary liver cancer. Liver resection or liver transplantation is the therapeutic gold standards in patient with HCC related with or without underline liver disease. We present a video case of a 68-year-old woman admitted to our surgical and liver transplantation unit for HCC on liver segment VII. Patient has HCV cirrhosis. Patient underwent to previous right portal vein embolization. Model of end staged liver disease was 7. Body mass index (BMI) was 26.3 and ASA score was 2. Alpha-fetoprotein was 768. According with our multidisciplinary group, we suggest a laparoscopic right hepatectomy for the patient. Operation time was 343 min and blood loss estimation was 200 CC. No transfusion was required. Post-operative course was uneventful, grade 0 of Clavien-Dindo Classification. Patient was discharged in day 7. Pathology report describes a 17 mm × 15 mm HCC grade 4, pT2N0. Laparoscopic liver resection (LLR) for HCC should be performed by dedicated surgical teams in hepatobiliary and laparoscopic surgery. The use of LLR in cirrhotic patients is in many centers proposed as the first-line treatment for HCC or as bridge treatment before liver transplantation.

Learning curve of self-taught laparoscopic liver surgeons in left lateral sectionectomy: results from an international multi-institutional analysis on 245 cases

BACKGROUND

Laparoscopy was suggested as gold standard for left lateral sectionectomy (LLS), thanks to recognized benefits compared to open approach. Aim of this study was to define learning curve (LC) of laparoscopic LLS (LLLS) using operative time (OT) as tool to analyze outcome of procedures performed by four experienced surgeons. Reproducibility and safety of LC in LLLS among independent surgeons were also analyzed as essential features of "standard procedure" concept.

METHODS

LLLS performed by four experienced surgeons was collected. Multivariate analysis was carried out to screen factors affecting OT. A cumulative LC was created calculating median OT. Skewness of OT was analyzed, and ROC curve was carried out to identify the cutoff for LC. The impact of LC on outcomes (morbidity and mortality, blood loss, conversions, surgical margins and length of stay) was determined.

RESULTS

A total of 245 LLLSs were collected. Conversion rate was 1.2 %. Median OT was 141 min, blood loss 100 mL, morbidity 11.4 % and mortality 0.4 %. "Associated procedures" was the only independent factor affecting OT. The skewness of the OT was calculated, and the cutoff point for LC was determined after 15 LLLSs. LLLS performed during and after LC period had similar outcomes.

CONCLUSION

LLLS is feasible with low morbidity, mortality and conversion rate. LC in LLLS is shorter compared to minor liver resections. Furthermore, it is reproducible and safe since it does not negatively affect clinical outcome. A reproducible, safe and short LC contributes to considering laparoscopy as the gold standard approach to perform LLS.

Surgical outcomes after laparoscopic or robotic liver resection in hepatocellular carcinoma: a propensity-score matched analysis with conventional open liver resection

BACKGROUND

This study was designed to compare perioperative and oncologic outcomes between minimally invasive liver resection (MILR) and conventional open liver resection (COLR) for hepatocellular carcinoma (HCC) using a propensity-score matched analysis.

METHODS

Ninety-nine patients who received MILR were matched with 198 patients treated with COLR out of 928 patients with HCC who received curative liver resection from 2002 to 2012. A multivariable logistic model based on factors related to the patient, tumor, and surgical procedure was used to estimate a propensity score.

RESULTS

The MILR group experienced significantly less intraoperative blood loss (mean: 389.55 vs 580.66 mL; P = 0.008), lower complication rates (13.1% vs 24.7%; P = 0.020), and a shorter length of hospital stay (mean: 8.40 vs 13.39 days; P < 0.001). The two groups did not differ significantly in disease-free (P = 0.701) or overall survival (P = 0.086).

CONCLUSIONS

MILR produced better perioperative and comparable oncologic outcomes than COLR for HCC. Copyright © 2015 John Wiley & Sons, Ltd.

Postoperative complications affect early recurrence of hepatocellular carcinoma after curative resection

BACKGROUND

Postoperative recurrence remains the major cause of death after curative resection for hepatocellular carcinoma (HCC). This study was conducted to evaluate the impact of postoperative complications on HCC recurrence after curative resection.

METHODS

The postoperative outcomes of 274 HCC patients who underwent curative resection were analysed retrospectively.

RESULTS

Of the 247 HCC patients, 103 (37.6 %) patients developed postoperative complications. The occurrence of postoperative complications was found to be associated with a significantly higher tumor recurrence (76.2 % vs. 56.6 %, P = 0.002) and a lower 5-year overall survival rate (27.7 % vs. 42.1 %; P = 0.037) as compared with those without complications. Regarding the recurrence pattern, early recurrence (≤2 years) was more frequently seen in patients with complications than that in patients without complications (54.5 % vs.38.6 %; P = 0.011). Multivariate analysis indicated that postoperative complications occurrence was an independent risk factor for early recurrence (odds ratio [OR] 2.223; 95 % confidence intervals [95 % CI] 1.161-4.258, P = 0.016) and poor overall survival (OR 1.413; 95 % CI, 1.012-1.971, P = 0.042).

CONCLUSIONS

The results of the present study indicate that the occurrence of postoperative complications is a predictive factor for HCC recurrence after curative hepatectomy, especially for early recurrence.

Laparoscopic liver resection for hepatocellular carcinoma in cirrhotic patients: single center experience of 90 cases

BACKGROUND

Hepatocellular carcinoma (HCC) with or without underlying liver disease can be treated by surgical resection. The aim of this study was to evaluate the feasibility, morbidity and mortality of a laparoscopic approach in cirrhotic patients with HCC.

METHODS

From 2004 to September 2014, 90 patients underwent a laparoscopic liver resection (LLR) for HCC. Data were collected in a prospectively maintained database since 2001. Preoperative patient evaluation was based on a multidisciplinary team meeting assessment.

RESULTS

Median age was 63 years; 67 (74.4%) patients were male. Median body mass index (BMI) was 26.7. Underlying liver disease was known in 68 patients: in 46 patients' hepatitis C virus (HCV)-related, in 15 patients to hepatitis B virus (HBV)-related, in 5 patients alcohol-related. Child-Pugh Score was of grade A in 85 patients and of grade B in 5 patients; 63 patients had a Model for End-stage Liver Disease (MELD) <10 and 27 patients MELD >10. A total of 18 left lateral sectionectomies, 1 left hepatectomy and 71 wedge resections or segmentectomies were performed. Conversion to laparotomy was necessary in 7 (7.7%) patients (five cases for bleeding and two cases for oncological reasons). In 90 patients, 98 HCC nodules were resected: 79 patients had one nodule, 8 patients had two nodules and 1 patient had three nodules. HCC nodules medium diameter was 29 mm (range, 4-100 mm) with median value of 25 mm. Tumor margins distance was 16 mm (range, 0-35 mm) with a median of 5 mm. Seventy nodules were located within the anterior sectors and 28 nodules within the posterior sectors.

CONCLUSIONS

LLR for HCC can be performed with acceptable morbidity in patients with underlying liver disease. The use of laparoscopic surgery in cirrhotic patients may be proposed as the first-line treatment for HCC or as bridge treatment before liver transplantation.

Hepatocellular carcinoma: From clinical practice to evidence-based treatment protocols

Hepatocellular carcinoma (HCC) is one of the major malignant diseases in many healthcare systems. The growing number of new cases diagnosed each year is nearly equal to the number of deaths from this cancer. Worldwide, HCC is a leading cause of cancer-related deaths, as it is the fifth most common cancer and the third most important cause of cancer related death in men. Among various risk factors the two are prevailing: viral hepatitis, namely chronic hepatitis C virus is a well-established risk factor contributing to the rising incidence of HCC. The epidemic of obesity and the metabolic syndrome, not only in the United States but also in Asia, tend to become the leading cause of the long-term rise in the HCC incidence. Today, the diagnosis of HCC is established within the national surveillance programs in developed countries while the diagnosis of symptomatic, advanced stage disease still remains the characteristic of underdeveloped countries. Although many different staging systems have been developed and evaluated the Barcelona-Clinic Liver Cancer staging system has emerged as the most useful to guide HCC treatment. Treatment allocation should be decided by a multidisciplinary board involving hepatologists, pathologists, radiologists, liver surgeons and oncologists guided by personalized -based medicine. This approach is important not only to balance between different oncologic treatments strategies but also due to the complexity of the disease (chronic liver disease and the cancer) and due to the large number of potentially efficient therapies. Careful patient selection and a tailored treatment modality for every patient, either potentially curative (surgical treatment and tumor ablation) or palliative (transarterial therapy, radioembolization and medical treatment, i.e., sorafenib) is mandatory to achieve the best treatment outcome.

Perspective of laparoscopic liver resection for hepatocellular carcinoma

Liver resection (LR) for hepatocellular carcinoma (HCC) in patients with chronic liver disease (CLD) is associated with high risks of developing significant postoperative complications and multicentric metachronous lesions, which can result in the need for repeated treatments. Studies comparing laparoscopic procedures to open LR consistently report reduced blood loss and transfusions requirements, lower postoperative morbidity, and shorter hospital stays, with no differences in oncologic outcomes. In addition, laparoscopic LR is associated with reduced postoperative ascites and a lower incidence of liver failure for HCC patients with CLD, due to the reduced surgery-induced parenchymal injury to the residual liver and limited destruction of the collateral blood/lymphatic flow around the liver. Finally, this procedure facilitates subsequent repeat LR due to minimal adhesion formation and improved vision/manipulation between adhesions. These characteristics of laparoscopic LR may lead to an expansion of the indications for LR. This editorial is based on the review and meta-analysis presented at the 2^nd International Consensus Conference on Laparoscopic Liver Resection in Iwate, Japan, in October 2014 (Chairperson of the congress is Professor Go Wakabayashi from the Department of Surgery, Iwate Medical University School of Medicine), which is published in the Journal of Hepato-Biliary-Pancreatic Sciences.

Outcomes of robotic vs laparoscopic hepatectomy: A systematic review and meta-analysis

AIM

To perform a systematic review and meta-analysis on robotic-assisted vs laparoscopic liver resections.

METHODS

A systematic literature search was performed using PubMed, Scopus and the Cochrane Library Central. Participants of any age and sex, who underwent robotic or laparoscopic liver resection were considered following these criteria: (1) studies comparing robotic and laparoscopic liver resection; (2) studies reporting at least one perioperative outcome; and (3) if more than one study was reported by the same institute, only the most recent was included. The primary outcome measures were set for estimated blood loss, operative time, conversion rate, R1 resection rate, morbidity and mortality rates, hospital stay and major hepatectomy rates.

RESULTS

A total of 7 articles, published between 2010 and 2014, fulfilled the selection criteria. The laparoscopic approach was associated with a significant reduction in blood loss and lower operative time (MD = 83.96, 95%CI: 10.51-157.41, P = 0.03; MD = 68.43, 95%CI: 39.22-97.65, P < 0.00001, respectively). No differences were found with respect to conversion rate, R1 resection rate, morbidity and hospital stay.

CONCLUSION

Laparoscopic liver resection resulted in reduced blood loss and shorter surgical times compared to robotic liver resections. There was no difference in conversion rate, R1 resection rate, morbidity and length of postoperative stay.