Laparoscopic hepatic left lateral lobectomy combined with fiber choledochoscopic exploration of the common bile duct and traditional open operation

Clinical and economic comparison of laparoscopic versus open hepatectomy for primary hepatolithiasis: a propensity score-matched cohort study

BACKGROUND

It is unclear whether laparoscopic hepatectomy (LH) for hepatolithiasis confers better clinical benefit and lower hospital costs than open hepatectomy (OH). This study aim to evaluate the clinical and economic value of LH versus OH.

METHODS

Patients undergoing OH or LH for primary hepatolithiasis at Yijishan Hospital of Wannan Medical College between 2015 and 2022 were divided into OH group and LH group. Propensity score matching (PSM) was used to balance the baseline data. Deviation-based cost modelling and weighted average median cost (WAMC) were used to assess and compare the economic value.

RESULTS

A total of 853 patients were identified. After exclusions, 403 patients with primary hepatolithiasis underwent anatomical hepatectomy (OH n=143; LH n=260). PSM resulted in 2 groups of 100 patients each. Although LH required a longer median operation duration compared with OH (285.0 versus 240.0 min, respectively, P<0.001), LH patients had fewer wound infections, fewer pre-discharge overall complications (26 versus 43%, respectively, P=0.009), and shorter median postoperative hospital stays (8.0 versus 12.0 days, respectively, P<0.001). No differences were found in blood loss, major complications, stone clearance, and mortality between the two matched groups. However, the median overall hospital cost of LH was significantly higher than that of OH (CNY¥52,196.1 versus 45,349.5, respectively, P=0.007). Although LH patients had shorter median postoperative hospital stays and fewer complications than OH patients, the WAMC was still higher for the LH group than for the OH group with an increase of CNY¥9,755.2 per patient undergoing LH.

CONCLUSION

The overall clinical benefit of LH for hepatolithiasis is comparable or even superior to that of OH, but with an economic disadvantage. There is a need to effectively reduce the hospital costs of LH and the gap between costs and diagnosis-related group reimbursement to promote its adoption.

Biliary Tract Exploration After Laparoscopic Left-sided Hepatectomy: A Comparative Study of Left Hepatic Duct Orifice Versus Common Bile Duct Approach

BACKGROUND

Laparoscopic left-sided hepatectomy (LLH) and additional biliary tract exploration are effective methods to treat left-sided hepatolithiasis (LSH) combined with extrahepatic bile duct stones. Although biliary tract exploration through common bile duct (CBD) incision has been widely accepted, the safety and effectiveness of the left hepatic duct (LHD) orifice approach after LLH is still in debate.

METHODS

One hundred and forty-four patients with LSH who underwent LLH and biliary tract exploration in our institution from April 2014 to September 2021 were enrolled in the retrospectively study. They were divided into 3 groups: LHD group (n=67), CBD/T-tube group (n=58), and CBD/PC group (n=19). Patients' demographic characteristics, intraoperative, and postoperative outcomes were retrospectively analyzed.

RESULTS

LHD group exhibited a shorter operative time (202.8±42.2 vs. 232.7±47.5 min, P=0.000), time to first bowel movement (2.3±0.5 vs. 2.9±0.7 d, P=0.000) and postoperative hospital stay (7.5±2.1 vs. 9.8±5.2 d, P=0.001) compared with the CBD/T-tube group. The lithotomy time in the LHD group was significantly longer than that in the CBD/T-tube group (33.6±7.3 vs. 29.0±6.3 min, P=0.000) and CBD/PC group (33.6±7.3 vs. 28.7±3.7, P=0.006). Intraoperative blood loss, blood transfusion rate, initial stone clearance rate, and stone recurrence rate all had no significant differences between the 3 groups (all P>0.05). LHD group showed less rate of electrolyte imbalance than that of the CBD/T-tube group (3.0% vs. 19.0%, P=0.004) but it was equivalent to the CBD/PC group (P>0.05). The type of biliary tract exploration (odds ratio: 5.43, 95% confidence interval: 0.04-0.95, P=0.032) as independent predictors of electrolyte imbalance. No reoperation and mortality occurred in the 3 groups. The conversion rate was comparable among 3 groups (1.5% vs. 1.7% vs. 0, all P>0.05). No significant difference in stone recurrence rate was seen (1.5% vs. 3.4% vs. 0, all P>0.05).

CONCLUSION

Biliary tract exploration through LHD orifice after LLH is a safe and effective treatment for selected patients with LSH, with an advantage over the T-tube drainage in the field of operative time, the incidence of electrolyte imbalance, recovery of gastrointestinal function, and postoperative hospital stay.

Biliary tract exploration via left hepatic duct stump versus the common bile duct incision in left-sided hepatolithiasis: a meta-analysis

BACKGROUND

Left lateral hepatic resection is the preferred surgical approach for treating left hepatolithiasis. However, it is not clear whether cholangioscopy via left hepatic duct (LHD) orifice can replace conventional common bile duct (CBD) approach during laparoscopic procedures.

METHODS

We performed a comprehensive literature search by screening medical databases, then compared perioperative outcomes and occurrence of recurrent stones between LHD and CBD approaches.

RESULTS

A total of five studies, comprising 345 patients, were included in this meta-analysis. The reported operative times, intra-operative blood loss and incidence of post-operative complications were comparable between the approaches. Pooled results revealed a positive correlation between LHD approach with shorter length of hospital stay (standard mean difference = -1.36; 95% confidence interval: -2.10, -0.61; P < 0.001). Additionally, bile duct exploration via LHD orifice was associated with similar rate of recurrent stones and cholangitis across both groups.

CONCLUSIONS

Our results demonstrated that biliary tract exploration via LHD stump can be safely performed in left-sided hepatolithiasis. Additionally, the LHD approach was associated with comparable intra-operative outcomes and shorter post-operative hospitalization relative to CBD approach, and does not increase incidence of stone recurrence.

Economic analysis of open versus laparoscopic versus robotic hepatectomy: a systematic review and meta-analysis

BACKGROUND

Following the publication of reports from landmark international consensuses (Louisville 2008 and Morioka 2014), minimally invasive hepatectomy became widely accepted as a legitimate alternative to open surgery. We aimed to compare the operative, hospitalization, and total economic costs of open (OLR) vs. laparoscopic (LLR) vs. robotic liver resection (RLR).

METHODS

We performed a systematic literature review (end-of-search date: July 3, 2020) according to the PRISMA statement. Random-effects meta-analyses were conducted. Quality assessment was performed with the Cochrane Risk of Bias tool for randomized controlled trials, and the Newcastle-Ottawa Scale for non-randomized studies.

RESULTS

Thirty-eight studies reporting on 3847 patients (1783 OLR; 1674 LLR; 390 RLR) were included. The operative costs of LLR were significantly higher than those of OLR, while subgroup analysis also showed higher operative costs in the LLR group for major hepatectomy, but no statistically significant difference for minor hepatectomy. Hospitalization costs were significantly lower in the LLR group, with subgroup analyses indicating lower costs for LLR in both major and minor hepatectomy series. No statistically significant difference was observed regarding total costs between LLR and OLR both overall and on subgroup analyses in either major or minor hepatectomy series. Meta-analyses showed higher operative, hospitalization, and total costs for RLR vs. LLR, but no statistically significant difference regarding total costs for RLR vs. OLR.

CONCLUSION

LLR's higher operative costs are offset by lower hospitalization costs compared to OLR leading to no statistically significant difference in total costs, while RLR appears to be a more expensive alternative approach.

Clinical application for DSA combined with a double-chamber Fogarty catheter in the treatment of venous crisis

Introduction

Venous crisis, as a common vascular crisis post limb replantation, is usually treated with surgical exploration.

Aim

To investigate effects of digital subtraction angiography (DSA) combined with double-chamber Fogarty balloon catheter on venous crisis post replantation of limbs.

Material and methods

Twelve patients suffering from severed limbs were involved in this study. Patients underwent DSA combining double-chamber Fogarty balloon catheter operation. Colour Doppler ultrasound was used to diagnose patients with venous crisis. Patients were treated with rehydration, anti-infection, anticoagulation, and vasodilation. Indexes, including total joint active activity, working condition, remaining symptoms, appearance, feeling, and muscle strength, were evaluated.

Results

During operation, the limb was shortened to 0-1 cm in 8 cases, to 1-2 cm in 2 cases, and to 2-2.5 cm in 2 cases. According to DSA findings, popliteal vein thrombosis was formed at 0.6-4.2 cm and was removed from the popliteal vein. After removal of the thrombosis, DSA images showed re-canalization of the popliteal vein. A typical case of a 16-year-old patient underwent limb replantation; however, venous crisis was formed post operation. Postoperative colour Doppler ultrasound findings indicated re-canalization of the popliteal vein. Tibia and fibula were reduced and internally fixed, while the limb was survived post-operation. The degree of swelling of limbs was improved, and skin temperature was normal or 0.6-1.5°C lower than affected limbs. Skin colour was normal and activity was improved. Patients demonstrated sensory recovery grade of S³⁺ and two-point discrimination of 4.5 mm.

Conclusions

DSA combining double-chamber Fogarty balloon catheter, as a minimally invasive and fast approach, could accurately locate thrombi and improve pertinence of vein branches.

Left liver anatomical resection via the left vertical groove and intraoperative antegrade cholangioscopy in patients with left-sided hepatolithiasis and previous biliary tract surgery

Objective

This study aimed to assess the safety and efficacy of left liver anatomical resection via the left vertical groove following intraoperative antegrade cholangioscopy (biliary exploration through the left hepatic duct orifice) in patients with left-sided hepatolithiasis (LSH) and previous biliary tract surgery.

Methods

Between January 2012 and January 2016, eligible patients with LSH (n = 28) who underwent left liver anatomical resection via the left vertical groove followed by intraoperative antegrade cholangioscopy, were referred to our hospital. Clinical results, such as the overall operative time, length of hospital stay, intraoperative complications, residual stones and postoperative bile leaks, were recorded and analyzed.

Results

No residual stones and bile leakage occurred in the patients. No patients experienced intraoperative complications or T-tube placement. The mean operative time was 135.1 ± 18.9 minutes. The mean postoperative duration of hospitalization was 7.8 ± 1.8 days.

Conclusions

Left liver anatomical resection via the left vertical groove combined with intraoperative antegrade cholangioscopy is a safe and useful method for patients with LSH and previous biliary tract surgery. This technique simplifies the operative procedure by avoiding dissection of the porta hepatis and subsequent choledochotomy.

Laparoscopic hepatectomy produces better outcomes for hepatolithiasis than open hepatectomy: An updated systematic review and meta-analysis

BACKGROUND

The present meta-analysis focused on comparing the efficacy and safety of laparoscopic hepatectomy (LH) versus open hepatectomy (OH) for hepatolithiasis. In detail, short-term outcomes including operative time, intraoperative blood loss, intraoperative blood transfusion, postoperative time to oral intake, length of hospital stay, overall postoperative complication rate, initial residual stone, and stone recurrence were analyzed systematically.

METHODS

PubMed, Embase, Web of Science and Cochrane Library were comprehensively searched for eligible studies up to Jun. 30. 2017. Bibliographic citation management software (EndNoteX7) was applied to literature management. Quality assessment was carried out according to the modification of the Newcastle-Ottawa Scale (NOS). The data were analyzed by Stata SE12.0 (StataCorp, College Station, TX). Sensitivity analysis was conducted by deleting single study step by step. Odds ratio (OR) were calculated for dichotomous data, and standard mean difference (SMD) with 95% confidence intervals (CI) was calculated continuous data.

RESULTS

= 0%; P = 0.22). In addition, our stratified analysis according to types of LH indicated that the laparoscopic approach still produced more favorable outcomes whatever patients underwent left lateral sectionectomy (LLS) or left hemihepatectomy (LHH).

CONCLUSION

The laparoscopic hepatectomy is a better alternative to open approach in patients with hepatolithiasis, providing less overall complication rate, shorter postoperative stay of hospital stay, less blood loss, and shorter time to oral intake. However, high-quality randomized controlled trials (RCTs) are badly needed to provide higher-level evidence due to unavoidable bias from non-randomized trials.

Biliary exploration via the left hepatic duct orifice versus the common bile duct in left-sided hepatolithiasis patients with a history of biliary tract surgery: A randomized controlled trial

BACKGROUND

Hepatectomy and additional common bile duct exploration are required for the treatment of left-sided hepatolithiasis (LSH).

METHODS

Eligible LSH patients (n = 62) scheduled for open left lateral segmentectomy or left hemihepatectomy with intraoperative biliary exploration via the left hepatic duct orifice (LHD group, n = 35) or the common bile duct (CBD group, n = 27) were retrospectively studied. T-tube insertion was performed on selected patients. Primary outcome measures included overall operative time, length of hospital stay, intraoperative complications, residual stones, and postoperative bile leaks.

RESULTS

There were no residual stones observed in the 2 groups. Ten patients in the CBD group received T-tube placement, whereas no patients in the LHD group received T-tube placement. There were more patients in the CBD group suffered intraoperative complications and postoperative bile leakage than LHD group (P < .05). The LHD group had a significantly shorter operative time and hospitalization than the CBD group (P < .05).

CONCLUSION

For left-sided hepatolithiasis patients with a history of biliary tract surgery, LHD cholangioscopy is an accessible technique that simplifies the operation procedure by avoiding choledochotomy and subsequent T-tube insertion, which results in lower complication rates as well as shorter operative duration and length of hospitalization.

Laparoscopic left-sided hepatectomy for the treatment of hepatolithiasis: A comparative study with open approach

BACKGROUND

Hepatolithiasis is a prevalent disease in some regions of China. Left-sided hepatectomy is an effective treatment for left intrahepatic bile duct stones with irreversible disease, such as biliary strictures, severe parenchymal fibrosis or atrophy. However, the advantages of laparoscopic left-sided hepatectomy (LLH) over open approach (OLH) are still controversial. The aim of this study was to compare the clinical outcomes of LLH to those of OLH in the treatment of hepatolithiasis.

METHODS

Between January 2013 and October 2016, 75 consecutive patients with hepatolithiasis undergoing left-sided hepatectomy were enrolled in this study. The demographic, intraoperative, and postoperative data were retrospectively analyzed.

RESULTS

Among these 75 patients, 36 underwent LLH (LLH group) and 39 underwent OLH (OLH group). The LLH group exhibited a lower intraoperative blood loss (215.8 ± 75.8 vs 298.7 ± 158.9 mL, p = 0.005), intraoperative transfusion (5.6% vs 23.1%, p = 0.032), overall complication rate (13.9% vs 35.9%, p = 0.029), and shorter recovery of bowel movement (2.3 ± 0.8 vs 3.0 ± 1.0 d, p = 0.004), time of off-bed activities (3.2 ± 1.1 vs 5.8 ± 1.4 d, p < 0.001) and postoperative hospital stay (7.7 ± 2.2 vs 10.9 ± 3.3 d, p < 0.001) compared to the OLH group. Similar results were also observed in left lateral sectionectomy and hemihepatectomy subgroups. There was no significant difference in the operative time, initial stone clearance rate, final stone clearance rate, stone recurrence rate and overall cost (All p > 0.05). No perioperative mortality was observed. The conversion rate was 5.6%.

CONCLUSION

LLH is a safe and effective treatment for selected patients with hepatolithiasis, with an advantage over OLH in the field of intraoperative blood loss, intraoperative transfusion, overall complication and postoperative recovery.

Laparoscopic Versus Open Left-Sided Hepatectomy for Hepatolithiasis: A Systematic Review and Meta-Analysis

BACKGROUND

Although laparoscopic left hepatectomy (LLH) for hepatolithiasis had been successfully performed in a series of cases, its advantages over open left hepatectomy (OLH) are still uncertain. This meta-analysis is to compare the clinical outcomes of LLH with those of OLH.

MATERIALS AND METHODS

A systematic literature research was performed to identify comparative studies on LLH versus OLH for hepatolithiasis from January 1991 to May 2016. Operative outcomes, postoperative outcomes, and gallstone clearance rate were evaluated. Pooled odds ratios and weighted mean differences with 95% confidence intervals were calculated using fixed-effect or random-effect models.

RESULTS

Eight studies, including one randomized controlled trial (RCT) and seven nonrandomized observational clinical studies, met the inclusion criteria. There were 739 patients in this meta-analysis, including 316 LLHs and 423 OLHs. The volume of intraoperative blood loss favored LLH (P = .015). Intraoperative transfusion (P < .001), overall complication (P < .001), and hospital stay (P = .001) were significantly low in LLH. There was no obvious difference in operation time, residual stone rate, and recurrent stone rate. The mean conversion rate was 9.5% (range, 2.2%-15.6%).

CONCLUSION

LLH seems to be more effective and safer for selected patients with hepatolithiasis than OLH. As only one RCT was included, the evidence of which is still limited. More prospective, multicenter, and RCTs are needed to further define the real role of the laparoscopic technique in hepatolithiasis.

Lithotomy using cholangioscopy via the left hepatic duct orifice versus the common bile duct in laparoscopic treatment of left-sided hepatolithiasis: a comparative study

OBJECTIVE

Laparoscopic hepatectomy is widely used in the surgical treatment of left-sided hepatolithiasis (LSH). Lithotomy using a cholangioscope usually is required for the treatment of concurrent right-sided hepatolithiasis or choledocholithiasis. The primary objective of this study was to evaluate the effectiveness and safety of gallstone elimination using cholangioscopy through the left hepatic duct (LHD) orifice versus the common bile duct (CBD).

PATIENTS AND METHODS

Eligible LSH patients (n=41) were scheduled for laparoscopic left lateral segmentectomy or left hemihepatectomy with intraoperative biliary exploration using cholangioscopy through the LHD orifice (LHD group, n=23) or the CBD (CBD group, n=18) at the discretion of patients. Laparoscopic T-tube insertion was performed in selected patients. Patients were regularly followed up at monthly intervals or more frequently in the presence of any symptom. The primary outcome measures included overall operative time, duration of the cholangioscopy procedure, volume of blood loss, length of hospital stay, and frequency of procedure-related complications.

RESULTS

The two groups were comparable in sex, age, symptoms, site of lesion, and gallstone comorbidities (P>.05). Of the 18 patients in the CBD group, 12 (66.7%) patients had a T-tube inserted in contrast to 1 (4.5%) patient in the LHD group. The two groups were comparable in cholangioscopy duration and volume of blood loss (P>.05), whereas the LHD group had a significantly shorter operative time than the CBD group (221.4 ± 58.6 minutes versus 171.2 ± 63.5 minutes; P<.05). The postoperative duration of hospitalization was significantly shorter in the LHD group than in the CBD group (7.5 ± 2.2 days versus 4.2 ± 1.9 days; P<.05). No patient showed any recurrence of gallstones or cholangitis during the follow-up period.

CONCLUSIONS

As an effective and safe technique that is comparable to choledochotomy, LHD cholangioscopy is a preferred alternative to choledochotomy in the laparoscopic treatment of LSH because it offers patients shorter operative duration and length of hospitalization.

Laparoscopic vs open left hepatectomy for hepatolithiasis

AIM

To explore the feasibility and therapeutic effect of total laparoscopic left hepatectomy (LLH) for hepatolithiasis.

METHODS

From June 2006 to October 2009, 61 consecutive patients with hepatolithiasis who met the inclusion criteria for LLH were treated in our institute. Of the 61 patients with hepatolithiasis, 28 underwent LLH (LLH group) and 33 underwent open left hepatectomy (OLH group). Clinical data including operation time, intraoperative blood loss, postoperative complication rate, postoperative hospital stay time, stone clearance and recurrence rate were retrospectively analyzed and compared between the two groups.

RESULTS

LLH was successfully performed in 28 patients. The operation time of LLH group was longer than that of OLH group (158 +/- 43 min vs 132 +/- 39 min, P < 0.05) and the hospital stay time of LLH group was shorter than that of OLH group (6.8 +/- 2.8 d vs 10.2 +/- 3.4 d, P < 0.01). No difference was found in intraoperative blood loss (180 +/- 56 mL vs 184 +/- 50 mL), postoperative complication rate (14.2% vs 15.2%), and stone residual rate (intermediate rate 17.9% vs 12.1% and final rate 0% vs 0%) between the two groups. No perioperative death occurred in either group. Fifty-seven patients (93.4%) were followed up for 2-40 mo (mean 17 mo), including 27 in LLH group and 30 in OLH group. Stone recurrence occurred in 1 patient of each group.

CONCLUSION

LLH for hepatolithiasis is feasible and safe in selected patients with an equal therapeutic effect to that of traditional open hepatectomy.

Laparoscopic vs open left hepatectomy for hepatolithiasis

AIM: To explore the feasibility and therapeutic effect of total laparoscopic left hepatectomy (LLH) for hepatolithiasis.

METHODS: From June 2006 to October 2009, 61 consecutive patients with hepatolithiasis who met the inclusion criteria for LLH were treated in our institute. Of the 61 patients with hepatolithiasis, 28 underwent LLH (LLH group) and 33 underwent open left hepatectomy (OLH group). Clinical data including operation time, intraoperative blood loss, postoperative complication rate, postoperative hospital stay time, stone clearance and recurrence rate were retrospectively analyzed and compared between the two groups.

RESULTS: LLH was successfully performed in 28 patients. The operation time of LLH group was longer than that of OLH group (158 ± 43 min vs 132 ± 39 min, P < 0.05) and the hospital stay time of LLH group was shorter than that of OLH group (6.8 ± 2.8 d vs 10.2 ± 3.4 d, P < 0.01). No difference was found in intraoperative blood loss (180 ± 56 mL vs 184 ± 50 mL), postoperative complication rate (14.2% vs 15.2%), and stone residual rate (intermediate rate 17.9% vs 12.1% and final rate 0% vs 0%) between the two groups. No perioperative death occurred in either group. Fifty-seven patients (93.4%) were followed up for 2-40 mo (mean 17 mo), including 27 in LLH group and 30 in OLH group. Stone recurrence occurred in 1 patient of each group.

CONCLUSION: LLH for hepatolithiasis is feasible and safe in selected patients with an equal therapeutic effect to that of traditional open hepatectomy.

Laparoscopic versus open splenectomy for hypersplenism secondary to liver cirrhosis. Surg Laparosc Endosc Percutan Tech. 2009;19:258-262. [PMID: 19542858 DOI: 10.1097/sle.0b013e3181a6ec7c]

BACKGROUND

Since the first laparoscopic splenectomy (LS) in 1991, LS has become the gold standard for the removal of normal-to-moderately enlarged spleens in benign conditions. Compared with open splenectomy (OS), fewer postsurgical complications and better postoperative recovery were observed, but it is contraindicated for hypersplenism secondary to liver cirrhosis owing to technical difficulties associated with splenomegaly, well-developed collateral circulation, and increased risk of bleeding. With the improvements of laparoscopic technique, the concept is changing.

METHODS

OS and LS performed for hypersplenism secondary to liver cirrhosis at our institution were analyzed. Relationships between postoperative increases in platelet counts, white blood cell counts, hemoglobin, and liver function were examined. Perioperative data of LSs were compared with those of OSs, including operative time, blood loss, excised spleen weight, complications, and hospital stays.

RESULTS

A total of 216 splenectomies (135 OS and 81 LS) were performed from April 1999 to March 2007. Five laparoscopic cases were converted to open surgery owing to operative bleeding or bleeding of splenic fossa. The other 76 patients were performed LSs successfully. No major operative complications occurred. There was no operative death. Excised spleen weight >400 g was present in 56% of cases in this series. At 7 days postoperatively, the platelet counts, white blood cell counts, and hemoglobin significantly increased after open and laparoscopic surgeries, and increase of alanine aminotransferase, aspartate aminotransferase, total bilirubin, and directed bilirubin of LS were significantly different with open cases. Operation times of LS and OS were 2.9+/-0.7 hours and 2.6+/-0.6 hours, respectively. Blood losses were 150.6+/-135.4 mL and 633.8+/-340.3 mL (P<0.01), excised spleen weights were 585.7+/-184.6 g and 591.1+/-153.4 g (P>0.05), and hospital stay were 8.2+/-2.0 days and 11.9+/-3.8 days (P<0.01). Operative associated complications were noted in both LS and OS. Less blood loss, shorter hospital stay, and less impairment of liver function were observed in LS than OS.

CONCLUSIONS

LS is feasible, effective, and safe procedures for hypersplenism secondary to liver cirrhosis and contributes to less impairment of liver function, less blood loss, and shorter hospital stay.