Laparoscopic radical and conservative surgery for hydatid liver echinococcosis: PSM based comparative analysis of immediate and long-term outcomes.

BACKGROUND: The diffusion of laparoscopic radical surgery for hydatid liver echinococcosis remains limited. There are no published data on a comparative analysis of the immediate and long-term results of radical and conservative laparoscopic surgery for liver hydatid cysts. Comparison of the immediate and long-term outcomes after laparoscopic radical and conservative cystectomies was aimed. METHODS: HPB center (Center 1) and general surgery hospital in an endemic area (Center 2) participated in a retrospective study. Radical surgery included total, subtotal pericystectomy, and liver resection. Conservative surgery comprised cystectomy without/with partial pericystectomy. RESULTS: The total number of patients who underwent surgery for liver hydatid cysts was 213. Laparoscopic cystectomy was performed in 106 (50%) patients. This number included 47 radical laparoscopic cystectomy (Center 1). Conservative laparoscopic procedures were used in 59 patients (Center 2). Finally, twenty-seven pairs of patients were matched. Immediate outcomes were better for radical treatment in terms of severe morbidity, length of hospital stay, and time of abdominal drainage before and after PSM. The mean follow-up length was 23 (4-66) and 29 (6-66) months and the recurrence rate was 2% and 5% in groups of radical and conservative treatment respectively. No differences were found in 1-, 3-, and 5-year disease free survival. After second PSM for recurrence, 20 pairs were matched with no relapse of disease. CONCLUSION: Laparoscopic radical surgery leads to the better immediate outcomes and can be recommended as the preferred treatment option in a specialized HPB center. Conservative option is justified in general hospitals in endemic area for selected uncomplicated cysts.

A randomized prospective study of the immediate outcomes of the use of a hydro-jet dissector and an ultrasonic surgical aspirator for laparoscopic liver resection.

BACKGROUND: No prospective randomized trials comparing transection techniques for the liver parenchyma transection during laparoscopic liver resection have been performed. The aim of the study was to compare the immediate outcomes of hydro-jet dissection with ultrasonic surgical aspirator in laparoscopic liver parenchyma transection in a prospective randomized single-center study. METHODS: Consecutive patients with liver benign and malignant tumors presenting to a single center from May 2017 to May 2020 were enrolled in the study. The primary endpoint was the intraoperative estimated blood loss. The secondary endpoints included duration of parenchymal transection, morbidity, and overall hospital stay. RESULTS: A total of 68 patients were enrolled in the study, with 34 patients in each group. There were no differences between groups in the difficulty of resection (according to IWATE criteria and IMM score) and other basic surgical parameters. No differences were found in all primary and secondary endpoints except the expenditure. The cost of equipment was significantly higher in the group of ultrasonic aspirator. CONCLUSION: Despite the wider use of the ultrasonic aspirator in laparoscopic liver surgery, hydro-jet and ultrasonic surgical aspirators have shown similar efficacy and safety for transection of the liver parenchyma during laparoscopic resection.

Combining E-PASS model and disease specific risk factors to predict severe morbidity after liver and bile duct resection for perihilar cholangiocarcinoma.

BACKGROUND: Estimation of physiologic ability and surgical stress system (E-PASS) has been shown to be effective in predicting morbidity after surgery for perihilar cholangiocarcinoma (PHCC). Nevertheless, E-PASS does not include an assessment of the disease specific risk factors. The aim of the study was to estimate the combined impact of E-PASS and specific preoperative factors on major morbidity for PHCC patients. METHODS: A retrospective analysis of a prospectively collected data was performed. Severe morbidity according to complication comprehensive index was defined as ≥40 points. A value of comprehensive risk score (CRS) ≥1 was taken as critical. RESULTS: Multivariate analysis of perioperative data from 122 patients revealed significant impact of five factors (CRS ≥1, future liver remnant volume <50%, T4 stage, moderate and severe cholangitis, INR) on the risk of severe morbidity after resection. The AUC for the combination of these factors was classified as good predictive value (0.810, 95% CI 0.729-0.891) and poor predictive value (0.673, 95% CI 0.573-0.773) for CRS alone (p = 0.040). CONCLUSION: A combination of E-PASS with disease specific risk factors is a reliable predictive model for major morbidity for patients undergoing radical surgery for PHCC.

Comparative analysis of learning curve in complex robot-assisted and laparoscopic liver resection.

BACKGROUND: There is no comparative analysis of the learning curves for robot-assisted and laparoscopic liver resection. We aimed to compare learning curves in complex robotic and conventional laparoscopic liver resections with regards to estimation of the difficulty index score. METHODS: The results of 131 consecutive liver resections were analyzed retrospectively (40 robot-assisted and 91 laparoscopic). The learning curve evaluation was based on calculation of procedures number before significant change of the difficulty index for minimally invasive liver resection or the rate of posterosuperior segments resection. Groups of early and late experience were compared in every type of approach (robot-assisted and laparoscopic). RESULTS: Significant increase of difficulty index (from 5.0 [3.0-7.7] to 7.3 [4.3-10.2]) of robotic procedures required 16 procedures. It was necessary to perform 29 laparoscopic resections in order to significantly increase the rate of laparoscopic posterosuperior segments resection but without significant increase of difficulty index. The implementation of minimally invasive liver resection started with the robotic approach. CONCLUSION: The learning curve for robot-assisted liver resections is shorter in comparison with laparoscopic resections. The inclusion of robot-assisted resections in a minimally invasive liver surgery program may be useful to rapidly increase the complexity of laparoscopic liver resections.

Multi-port versus single-port cholecystectomy: results of a multi-centre, randomised controlled trial (MUSIC trial).

BACKGROUND: Single-port laparoscopic surgery as an alternative to conventional laparoscopic cholecystectomy for benign disease has not yet been accepted as a standard procedure. The aim of the multi-port versus single-port cholecystectomy trial was to compare morbidity rates after single-access (SPC) and standard laparoscopy (MPC). METHODS: This non-inferiority phase 3 trial was conducted at 20 hospital surgical departments in six countries. At each centre, patients were randomly assigned to undergo either SPC or MPC. The primary outcome was overall morbidity within 60 days after surgery. Analysis was by intention to treat. The study was registered with ClinicalTrials.gov (NCT01104727). RESULTS: The study was conducted between April 2011 and May 2015. A total of 600 patients were randomly assigned to receive either SPC (n = 297) or MPC (n = 303) and were eligible for data analysis. Postsurgical complications within 60 days were recorded in 13 patients (4.7 %) in the SPC group and in 16 (6.1 %) in the MPC group (P = 0.468); however, single-access procedures took longer [70 min (range 25-265) vs. 55 min (range 22-185); P < 0.001]. There were no significant differences in hospital length of stay or pain VAS scores between the two groups. An incisional hernia developed within 1 year in six patients in the SPC group and in three in the MPC group (P = 0.331). Patients were more satisfied with aesthetic results after SPC, whereas surgeons rated the aesthetic results higher after MPC. No difference in quality of life scores, as measured by the gastrointestinal quality of life index at 60 days after surgery, was observed between the two groups. CONCLUSIONS: In selected patients undergoing cholecystectomy for benign gallbladder disease, SPC is non-inferior to MPC in terms of safety but it entails a longer operative time. Possible concerns about a higher risk of incisional hernia following SPC do not appear to be justified. Patient satisfaction with aesthetic results was greater after SPC than after MPC.