Surgical outcomes of laparoscopic distal pancreatectomy in elderly and octogenarian patients: a single-center, comparative study.

BACKGROUND: Although recent reports have suggested the advantages of laparoscopic distal pancreatectomy (LDP), the potential benefits of this approach in elderly patients remain unclear. The aim of this study was to clarify the value of LDP in the elderly, in whom co-morbid diseases were generally more common. METHODS: Seventy elderly patients (≥ 70 years) and 264 non-elderly patients (40-69 years) who underwent LDP, and 48 elderly patients (≥ 70 years) who underwent open distal pancreatectomy (ODP) between May 2005 and May 2018 were studied. Demographics, intraoperative, and postoperative outcomes were compared. RESULTS: Comorbidity was more common in elderly patients than in non-elderly patients who underwent LDP (57.1 vs. 38.3%, p < 0.01). The intraoperative factors, postoperative complication rate, and length of hospital stay were comparable in these two groups. Elderly patients who underwent LDP had a significantly shorter operative time (185.5 vs. 208.0 min, p = 0.02), less blood loss (191.0 vs. 291.8 mL, p < 0.01), and reduced length of postoperative hospital stay (11.4 vs. 15.1 days, p < 0.01) than elderly patients who had ODP. The overall complication rate tended to be lower in LDP group than that in ODP group (20.0 vs. 33.3%, p = 0.07). CONCLUSION: LDP performed on the elderly is safe and feasible, leading to short-term outcomes similar to those of non-elderly patients. LDP could be an alternative to ODP in elderly patients, providing a lower rate of morbidity and favorable postoperative recovery and outcomes.

Expanding laparoscopic pancreaticoduodenectomy to pancreatic-head and periampullary malignancy: major findings based on systematic review and meta-analysis.

BACKGROUND: Laparoscopic pancreaticoduodenectomy (LPD) remains to be established as a safe and effective alternative to open pancreaticoduodenectomy (OPD) for pancreatic-head and periampullary malignancy. The purpose of this meta-analysis was to compare LPD with OPD for these malignancies regarding short-term surgical and long-term survival outcomes. METHODS: A literature search was conducted before March 2018 to identify comparative studies in regard to outcomes of both LPD and OPD for the treatment of pancreatic-head and periampullary malignancies. Morbidity, postoperative pancreatic fistula (POPF), mortality, operative time, estimated blood loss, hospitalization, retrieved lymph nodes, and survival outcomes were compared. RESULTS: Among eleven identified studies, 1196 underwent LPD, and 8247 were operated through OPD. The pooled data showed that LPD was associated with less morbidity (OR = 0.57, 95%CI: 0.41~ 0.78, P < 0.01), less blood loss (WMD = - 372.96 ml, 95% CI, - 507.83~ - 238.09 ml, P < 0.01), shorter hospital stays (WMD = - 197.49 ml, 95% CI, - 304.62~ - 90.37 ml, P < 0.01), and comparable POPF (OR = 0.85, 95%CI: 0.59~ 1.24, P = 0.40), and overall survival (HR = 1.03, 95%CI: 0.93~ 1.14, P = 0.54) compared to OPD. Operative time was longer in LPD (WMD = 87.68 min; 95%CI: 27.05~ 148.32, P < 0.01), whereas R0 rate tended to be higher in LPD (OR = 1.17; 95%CI: 1.00~ 1.37, P = 0.05) and there tended to be more retrieved lymph nodes in LPD (WMD = 1.15, 95%CI: -0.16~ 2.47, P = 0.08), but these differences failed to reach statistical significance. CONCLUSIONS: LPD can be performed as safe and effective as OPD for pancreatic-head and periampullary malignancy with respect to both surgical and oncological outcomes. LPD is associated with less intraoperative blood loss and postoperative morbidity and may serve as a promising alternative to OPD in selected individuals in the future.

Short-term outcomes of laparoscopic total gastrectomy for gastric cancer: a comparative study with laparoscopic distal gastrectomy at a high-volume center.

BACKGROUND: Laparoscopic distal gastrectomy (LDG) for gastric cancer has gradually gained popularity. However, laparoscopic total gastrectomy (LTG) has been reported rarely when compared with LDG. This study was designed to evaluate the surgical outcomes as well as the morbidity and mortality of LTG compared with LDG to confirm the feasibility and safety of LTG. MATERIAL AND METHODS: We reviewed the data of patients at our institution undergoing LTG (n = 448) or LDG (n = 956) for gastric cancer between January 2008 and July 2016. Then the clinical characteristics and perioperative clinical outcomes of the two groups were compared. RESULTS: Except for tumor size and stage, there were no statistically significant differences in the clinicopathological parameters between the groups. LTG was associated with significantly longer operation time, late time to postoperative diet, and longer hospital stay compared with the LDG group. Overall complications developed in 60 patients (13.4%) and surgical complications in 48 patients (10.7%) after LTG. Postoperative complications were less frequent in the LDG group than in the LTG group (8.4% versus 13.4%, p < .01), and fewer surgical complications were observed with LDG than with LTG (7.5% versus 10.7%, p = .05). CONCLUSIONS: The results of LTG were favorable even though are not inferior to those of LDG. LTG for gastric cancer is technically feasible and safe. However, because of the limits of this study, other high-quality studies are needed for further evaluation.

Minimally invasive pancreaticoduodenectomy for periampullary disease: a comprehensive review of literature and meta-analysis of outcomes compared with open surgery.

BACKGROUND: Minimally invasive pancreatoduodenectomy (MIPD) has been gradually attempted. However, whether MIPD is superior, equal or inferior to its conventional open pancreatoduodenectomy (OPD) is not clear. METHODS: Studies published up to May 2017 were searched in PubMed, Embase, Cochrane Library, and Web of Science. Main outcomes were comprehensively reviewed and measured including conversion to open approach, operation time (OP), estimated blood loss (EBL), transfusion, length of hospital stay (LOS), overall complications, postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), post-pancreatectomy hemorrhage (PPH), readmission, reoperation and reasons of preoperative death, number of retrieved lymph nodes (RLN), surgical margins, recurrence, and survival. The software of Review Manage version 5.1 was used for meta-analysis. RESULTS: One hundred studies were included for systematic review and 26 out of them (totally 3402 cases, 1064 for MIPD, 2338 for OPD) were included for meta-analysis. In the early years, most articles were case reports or non-control case series studies, while in the last 6 years high-volume and comparative researches were increasing gradually. Systematic review revealed conversion rates of MIPD to OPD ranged from 0% to 40%. The mean or median OP of MIPD ranged from 276 to 657 min. The total POPF rates vary between 3.8% and 50% observed in all systematic reviewed studies. Meta-analysis demonstrated MIPD had longer OP (WMD = 99.4 min; 95%CI: 46.0 ~ 152.8, P < 0.01), lower blood loss (WMD = -0.54 ml; 95% CI, -0.88 ~ -0.20 ml; P < 0.01), lower transfusion rate (RR = 0.73, 95%CI: 0.57 ~ 0.94, P = 0.02), shorter LOS (WMD = -3.49 days; 95%CI: -4.83 ~ -2.15, P < 0.01). There was no significant difference in time to oral intake, postoperative complications, POPF, reoperation, readmission, perioperative mortality and number of retrieved lymph nodes. CONCLUSION: Our study demonstrates MIPD is technically feasible and safety on the basis of historical studies. MIPD is associated with less blood loss, faster postoperative recovery, shorter length of hospitalization and longer operation time. These findings are waiting for being confirmed with robust prospective comparative studies and randomized clinical trials.

Laparoscopic gastrectomy in obese gastric cancer patients: a comparative study with non-obese patients and evaluation of difference in laparoscopic methods.

BACKGROUND: Obesity is a growing epidemic around the world, and obese patients are generally regarded as high risk for surgery compared with normal weight patients. The purpose of this study was to evaluate the influence of obesity on the surgical outcomes of laparoscopic gastrectomy (LG) for gastric cancer. METHODS: We reviewed data for all patients undergoing LG for gastric cancer at our institute between October 2004 and December 2016. Patients were divided into non-obese and obese groups and the perioperative outcomes were compared. Furthermore, a subgroup analysis was conducted to evaluate which of the two commonly used methods of LG, laparoscopic-assisted gastrectomy (LAG) and totally laparoscopic gastrectomy (TLG), is more suitable for obese patients. RESULTS: A total of 1691 patients, 1255 non-obese and 436 obese or overweight patients, underwent LG during the study period. The mean operation time was significantly longer in the obese group than in the non-obese group (209.9 ± 29.7 vs. 227.2 ± 25.7 min, P < 0.01), and intraoperative blood loss was significantly lower in the non-obese group (113.4 ± 34.1 vs. 136.9 ± 36.7 ml, P < 0.01). Time to first flatus, time to oral intake, and postoperative hospital stay were significantly shorter in the non-obese group than in the obese group (3.3 ± 0.8 vs. 3.6 ± 0.9 days; 4.3 ± 1.0 vs. 4.6 ± 1.0 days; and 9.0 ± 2.2 vs. 9.6 ± 2.2 days, respectively; P < 0.01). 119 (9.5%) of the non-obese patients had postoperative complications as compared to 44 (10.1%) of the obese patients (P = 0.71). In the subgroup analysis of all patients, TLG showed improved results for early surgical outcomes compared to LAG, mainly due to its advantages in obese patients. CONCLUSIONS: Obesity is associated with long operation time, increased blood loss, and slow recovery after laparoscopic gastric resection but does not affect intraoperative security or effectiveness. TLG may have less negative results in obese patients than LAG due to a variety of reasons. Our analysis shows that TLG is more advantageous, with regard to early surgical outcomes, for obese patients.

Robotic versus laparoscopic Gastrectomy for gastric cancer: a systematic review and updated meta-analysis.

BACKGROUND: Advanced minimally invasive techniques including robotic surgery are being employed with increasing frequency around the world, primarily in order to improve the surgical outcomes of laparoscopic gastrectomy (LG). We conducted a systematic review and meta-analysis to evaluate the feasibility, safety and efficacy of robotic gastrectomy (RG). METHODS: Studies, which compared surgical outcomes between LG and RG, were retrieved from medical databases before May 2017. Outcomes of interest were estimated as weighted mean difference (WMD) or risk ratio (RR) using the random-effects model. The software Review Manage version 5.1 was used for all calculations. RESULTS: Nineteen comparative studies with 5953 patients were included in this analysis. Compared with LG, RG was associated with longer operation time (WMD = -49.05 min; 95% CI: -58.18 ~ -39.91, P < 0.01), less intraoperative blood loss (WMD = 24.38 ml; 95% CI: 12.32 ~ 36.43, P < 0.01), earlier time to oral intake (WMD = 0.23 days; 95% CI: 0.13 ~ 0.34, P < 0.01), and a higher expense (WMD = -3944.8 USD; 95% CI: -4943.5 ~ -2946.2, P < 0.01). There was no significant difference between RG and LG regarding time to flatus, hospitalization, morbidity, mortality, harvested lymph nodes, and cancer recurrence. CONCLUSIONS: RG can be performed as safely as LG. However, it will take more effort to decrease operation time and expense.

Totally laparoscopic gastrectomy using intracorporeally stapler or hand-sewn anastomosis for gastric cancer: a single-center experience of 478 consecutive cases and outcomes.

BACKGROUND: Totally laparoscopic gastrectomy (TLG) using intracorporeal anastomosis has gradually become mature thanks to the advancements of laparoscopic surgical instruments and the accumulation of operative experience. The goal of this study is to review our institution's experience with TLG for the treatment of gastric cancer. METHODS: A retrospective study was conducted to examine the short-term outcomes of TLG using intracorporeally stapler or hand-sewn anastomosis performed at Sir Run Run Shaw Hospital between March 2007 and June 2015. The details of intracorporeal anastomosis were described, and the clinicopathological data, surgical outcomes, and postoperative complications were evaluated. RESULTS: Four hundred seventy-eight patients were included in the study. Generally speaking, the patients could be divided into stapler or hand-sewn groups according to whether intracorporeal anastomosis was performed by only hand-sewn technique (n = 97) or only stapling devices (n = 381). For overall patients, the mean operation time and anastomotic time were 225.7 and 30.0 min, respectively. Postoperative complications were observed in 65 patients. All of the patients recovered well without perioperative death by conservative or surgical management. CONCLUSIONS: TLG using intracorporeally stapler or hand-sewn anastomosis is a reasonable option for the treatment of gastric cancer, with early data showing acceptable perioperative outcomes.

Comparing the short-term outcomes of intracorporeal esophagojejunostomy with extracorporeal esophagojejunostomy after laparoscopic total gastrectomy for gastric cancer.

BACKGROUND: Totally laparoscopic distal gastrectomy (TLDG) using intracorporeal anastomosis has gradually developed due to advancements in laparoscopic surgical instruments. However, totally laparoscopic total gastrectomy (TLTG) with intracorporeal esophagojejunostomy (IE) is still uncommon because of technical difficulties. Herein, we evaluated various types of IE after TLTG in terms of the technical aspects. We compared the short-term operative outcomes between TLTG with IE and laparoscopy-assisted total gastrectomy (LATG) with extracorporeal esophagojejunostomy (EE). METHODS: Between March 2006 and December 2014, a total of 213 patients with gastric cancer underwent TLTG and LATG. Overall, 92 patients underwent TLTG with IE, and 121 patients underwent LATG with EE. Generally, there are two methods of IE: mechanical staplers (circular or linear staplers) and hand-sewn sutures. Surgical efficiencies and outcomes were compared between two groups. We also described various types of IE using a subgroup analysis. RESULTS: The mean operation times were similar in the two groups, as was the number of retrieved lymph nodes. However, the mean estimated blood loss of TLTG was statistically lower than LATG. There were no significant differences in time to first flatus, the time to restart oral intake, the length of the hospital stay after operation, and postoperative complications. Four types of IE have been applied after TLTG, including 42 cases of hand-sewn IE. The overall mean operation time and the mean anastomotic time in TLTG were 279.5 ± 38.4 min and 52.6 ± 18.9 min respectively. There was no case of conversion to open procedure. Postoperative complication occurred in 16 patients (17.4%) and no postoperative mortality occurred. CONCLUSIONS: IE is a feasible procedure and can be safely performed for TLTG with the proper laparoscopic expertise. It is technically feasible to perform hand-sewn IE after TLTG, which can reduce the cost of the laparoscopic procedure.

Development of an Aerobic Glycolysis Index for Predicting the Sorafenib Sensitivity and Prognosis of Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is a deadly tumor with high heterogeneity. Aerobic glycolysis is a common indicator of tumor growth and plays a key role in tumorigenesis. Heterogeneity in distinct metabolic pathways can be used to stratify HCC into clinically relevant subgroups, but these have not yet been well-established. In this study, we constructed a model called aerobic glycolysis index (AGI) as a marker of aerobic glycolysis using genomic data of hepatocellular carcinoma from The Cancer Genome Atlas (TCGA) project. Our results showed that this parameter inferred enhanced aerobic glycolysis activity in tumor tissues. Furthermore, high AGI is associated with poor tumor differentiation and advanced stages and could predict poor prognosis including reduced overall survival and disease-free survival. More importantly, the AGI could accurately predict tumor sensitivity to Sorafenib therapy. Therefore, the AGI may be a promising biomarker that can accurately stratify patients and improve their treatment efficacy.

Laparoscopic gastrectomy using intracorporeally hand-sewn anastomosis of esophagojejunostomy, gastroduodenostomy, or gastrojejunostomy for gastric cancer.

Laparoscopic gastrectomy (LG) using intracorporeal anastomosis has recently become more prevalent due to the advancements of laparoscopic surgical instruments. However, intracorporeally hand-sewn anastomosis (IHSA) is still uncommon because of technical difficulties. In this study, we evaluated various types of IHSA following LG with respect to the technical aspects and postoperative outcomes.Seventy-six patients who underwent LG using IHSA for treatment of gastric cancer between September 2014 and June 2018 were enrolled in this study. We described the details of IHSA in step-by-step manner, evaluated the clinicopathological data and surgical outcomes, and summarized the clinical experiences.Four types of IHSA have been described: one for total gastrectomy (Roux-en-Y) and 3 for distal gastrectomy (Roux-en-Y, Billroth I, and Billroth II). The mean operation time and anastomotic time was 288.7 minutes and 54.3 minutes, respectively. Postoperative complications were observed in 13 patients. All of the patients recovered well with conservative surgical management. There was no case of conversion to open surgery, anastomotic leakage, or mortality.LG using IHSA was safe and feasible and had several advantages compared to mechanical anastomosis. The technique lengthened operating time, but this could be mitigated by increased surgical training and experience.

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

BACKGROUND: Repeat laparoscopic hepatectomy (LRH) offers an option for recurrent tumors in liver remnants following an initial liver resection of recurrent hepatocellular carcinoma (HCC), colorectal liver metastasis (CRLM) and cholangiocellular carcinoma (CCC), showing advantages in some outcomes. The objective of the study was to evaluate the feasibility, safety, and potential benefits of LRH in comparison with repeat open hepatectomy (ORH) for recurrent liver cancer. METHODS: A systematic review was performed in compliance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) and AMSTAR (Assessing the methodological quality of systematic reviews) guidelines. We performed a systematic search of PubMed, Embase, Cochrane Library, and Web of Science to identify studies that compared LRH with ORH from inception to September 30, 2019. Outcomes of interest included operation time, intraoperative estimated blood loss, length of hospital stay, complication rate, transfusion and R0 resection rate. The protocol was registered with the PROSPERO register of systematic reviews. RESULTS: 10 retrospective observational studies were suitable for this analysis, involving 767 patients with 334 undergoing LRH (43.5%) and 433 undergoing ORH (56.5%). Compared with ORH, LRH had less intraoperative blood loss (SMD = -1.03; 95% CI: 1.48~-0.59, P < 0.001), less overall postoperative complications (OR = 0.40; 95% CI: 0.16-0.99, P = 0.048), less major complications (OR = 0.31, 95% CI: 0.15-0.62, P = 0.001), shorter hospital stay (SMD = -0.98; 95% CI: 1.41~-0.54, P < 0.001) and higher R0 resection rate (OR = 2.30, 95% CI: 1.39-3.81, P = 0.001). It was comparable in operation time (WMD = -7.66; 95% CI: 52.50-37.19, P = 0.738), transfusion rate (OR = 0.33; 95% CI:0.11-1.05, P = 0.060), and mortality (OR = 0.76; 95% CI: 0.27-2.18, P = 0.615) between LRH and ORH. CONCLUSION: Our results indicate that LRH is a safe and effective technique. Benefits, especially less intra-operative blood loss, less complications rate, shorter hospital stay and higher R0 resection, might be offered in the laparoscopic approach.

Laparoscopic hepatectomy for elderly patients: Major findings based on a systematic review and meta-analysis.

BACKGROUND: As the general population continues to age, there is an increase need for surgical management of elderly patients. Compared to open hepatectomy (OH), laparoscopic hepatectomy (LH) offers earlier mobilization, less blood loss, and shorter postoperative hospital stay. However, whether these advantages of LH over OH are retained in elderly patients remains to be clarified. Therefore, in this study, we sought to evaluate the feasibility, safety, and potential benefits of LH for elderly patients. METHODS: A systematic search of PubMed, Embase, Cochrane Library, and Web of Science was performed to identify studies that compared LH and OH. Studies comparing LH in elderly and LH in nonelderly patients were also identified. Outcomes of interest included conversion rate, operative time, intraoperative estimated blood loss, length of hospital stay, rate and type of morbidity, mortality rate, margin status (R0), and long-term oncologic outcomes. RESULTS: Nine studies met our inclusion criteria for this analysis. Of these, 5 compared LH and OH in elderly patients, 3 compared LH in elderly and nonelderly patients, and 1 included both outcomes. Compared to those with OH, elderly patients who underwent LH had similar operative times [weighted mean difference (WMD) = 1.15 minutes; 95% confidence interval (CI): -28.28-30.59, P = .94], less intraoperative blood loss (WMD = -0.71 mL; 95% CI: -1.29 to -0.16, P = .01), a lower rate of transfusion [risk ratio (RR) = 0.61, 95% CI: 0.40-0.94, P = .02], comparable R0 rates (RR = 1.01; 95% CI: 0.96-1.07, P = .70), less postoperative complications (RR = 0.61, 95% CI: 0.48-0.76, P < .01), and shorter hospital stay (WMD = -3.22 days; 95% CI: -4.21 to -2.23, P < .01). The limited long-term outcomes indicated that survival status was comparable between LH and OH for elderly patients. The pooled outcomes for elderly versus nonelderly patients indicated that the safety and effectiveness of LH over OH in elderly patients was not inferior to those in nonelderly patients. CONCLUSION: Our results indicate that LH is a feasible and safe alternative to OH in elderly patients, providing a lower rate of morbidity and favorable postoperative recovery and outcomes.

Laparoscopic versus open pancreatectomy for pancreatic ductal adenocarcinoma: A systematic review and meta-analysis.

BACKGROUND: Laparoscopic pancreatic surgery (LPS) has been widely used in the treatment of benign and low-grade pancreatic diseases. It is necessary to expand the current knowledge on the feasibility and safety of LPS for pancreatic ductal adenocarcinoma (PDAC) by systematic reviewing the published studies and analyzing them by meta-analysis. METHODS: Original articles compared LPS with open pancreatic surgery (OPS) for PDAC, published from January 1994 to August 2017 were searched in medical databases. Postoperative pancreatic fistula (POPF), morbidity, mortality, operation time, blood loss, transfusion, hospital stay, retrieved lymph nodes (RLNs), and survival outcomes were compared. RESULTS: Fourteen studies with a total of 13174 patients (1705 in LPS and 11469 in OPS) were included for the meta-analysis. LPS showed less morbidity (RR = 0.78, 95%CI: 0.66-0.92, P < .01), blood loss (WMD = -298.05 ml, 95% CI, -482.98∼-113.12 ml; P < .01), shorter hospital stay (WMD = -2.86, 95%CI, -3.85∼-1.87; P < .01), more RLNs (WMD = 1.47, 95%CI: 0.15-2.78; P = .03) and comparable POPF (RR = 1.12, 95%CI: 0.82-1.53, P = .50), operation time (WMD = 22.23 min; 95%CI: -19.56-64.01, P = .30), and 5-year overall survival (HR = 0.92, 95%CI: 0.80-1.06; P = .23) compared to OPS. CONCLUSION: LPS can be performed safely in carefully selected patients with PADC and would improve the surgical outcomes. Considering the limitation of study design, the conclusions should be interpret cautiously and warrant to be confirmed by randomized controlled studies.

Laparoscopic gastrectomy for elderly patients with gastric cancer: A systematic review with meta-analysis.

BACKGROUND: Laparoscopic gastrectomy (LG) has been widely applied in patients with gastric cancer (GC). However, the safety and application value of LG in elderly patients with GC was still unclear. In this study, we aimed to evaluate the feasibility and safety of LG for elderly patients with GC using the meta-analysis. METHODS: Studies comparing elderly patients and nonelderly patients who underwent LG for GC were reviewed and collected from the PubMed, EBSCO, Cochrane Library, and EMBASE. Outcomes such as operative results, postoperative recovery, and morbidity were compared and analyzed. The Review Manager 5.3 was used to portray the weighted mean difference (WMD) and odds ratio (OR) with a 95% confidence interval (CI). RESULTS: Eleven observational studies with a total of 3275 patients were included. Compared with nonelderly patients, elderly patients had shorter operation time (WMD -10.46; 95% CI -17.06 to -3.86; P = .002), less retrieved lymph nodes (WMD -2.34; 95% CI -3.77 to -0.92; P = .001), delayed time to first flatus (WMD 0.31; 95% CI 0.10-0.51; P = .003), longer postoperative hospital stays (WMD 1.06; 95% CI 0.07-2.05; P = .04), higher risk for overall postoperative complication (OR 1.34; 95% CI 1.08-1.67; P = .009), nonsurgical postoperative complication (OR 1.98; 95% CI 1.24-3.15; P = .004), and postoperative pulmonary complication (OR: 3.09; 95% CI 1.68-5.68; P < .001). There was no significance between nonelderly patients and elderly patients regarding the estimated blood loss, incidences of surgical postoperative complication, surgical site infection, and ileus (P > .05). CONCLUSION: Outcomes of LG for elderly patients were comparable to those in nonelderly patients. Age alone should not preclude LG in elderly patients.

Laparoscopic Versus Open Major Hepatectomy for Hepatocellular Carcinoma: A Meta-Analysis.

BACKGROUND: Although large series of laparoscopic resections for hepatocellular carcinoma (HCC) were published, reports of laparoscopic major hepatectomy (LMH) are still limited in expert centers because LMH for HCC remains a challenging procedure requiring extensive experience in both laparoscopic and hepatic surgery. We performed a meta-analysis to assess the safety and efficacy of LMH and open major hepatectomy (OMH) for HCC. METHODS: A literature search was performed to identify studies comparing LMH with OMH for HCC. Postoperative morbidity, mortality, operative time, intraoperative blood loss, length of hospital stay, R0 rate, and long-term survival outcomes were analyzed. RESULTS: Eight studies with a total of 780 HCC patients were included for meta-analysis. The pooled data showed that LMH was associated with longer operative time [weighted mean differences (WMD)=81.04 min; 95% confidence interval (CI), 37.95~124.13; P<0.01], less blood loss (WMD=-117.14 mL; 95% CI, -170.35~-63.93; P<0.01), and shorter hospital stay (WMD=-3.41 d; 95% CI, -4.90~-1.92; P<0.01). Overall morbidity was significantly lower in the LMH group (odds ratio=0.45; 95% CI, 0.23~0.86; P=0.02), as were major complications (odds ratio=0.36; 95% CI, 0.18~0.73; P<0.01). However, there was no difference in margin negativity and long-term survival outcomes. CONCLUSIONS: LMH can be performed as safely and efficiently as OMH for HCC regarding both surgical and oncological outcomes. LMH is associated with less intraoperative blood loss and postoperative morbidity and may serve as a promising alternative to OMH for HCC patients.

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.

The prospective of laparoscopic pancreaticoduodenectomy for cancer management.

Laparoscopic pancreaticoduodenectomy (LPD) is an extremely challenging surgery. First described in 1994, LPD has been gaining a favorable position in the majority of pancreatic surgery. Now, LPD is worldwide accepted. A literature search was conducted in PubMed, and only papers written in English containing more than 26 publications of LPD were selected. Papers in distal and robotic pancreatic procedure were not included in the review of a total of 222 LPD publications. The total number of patients analyzed was 1,082 from 25 articles and the largest series. Six of these studies came from the United States, 1 from France, 5 from South Korea, and 1 from India, 2 from Japan, 5 from China, 1 from Italy, 1 Germany, 2 from UK. The overall pancreatic fistula rate was 20.5%. The overall conversion rate was 10.4%. LPD seems to be a valid alternative to the standard open approach with similar technical and oncological results. LPD is a safe procedure, providing many of the advantages typically associated with laparoscopic procedures. We expect this operation to continue to gain in popularity as well as be offered in increasingly more complex cases. In future studies, it will be beneficial to look further at the oncologic outcome data of LPD including survival.

Laparoscopy-Assisted versus Open Hepatectomy for Live Liver Donor: Systematic Review and Meta-Analysis.

OBJECTIVE: To assess the feasibility, safety, and potential benefits of laparoscopy-assisted living donor hepatectomy (LADH) in comparison with open living donor hepatectomy (ODH) for liver transplantation. BACKGROUND: LADH is becoming increasingly common for living donor liver transplant around the world. We aim to determine the efficacy of LADH and compare it with ODH. METHODS: A systematic search on PubMed, Embase, Cochrane Library, and Web of Science was conducted in May 2017. RESULTS: Nine studies were suitable for this analysis, involving 979 patients. LADH seemed to be associated with increased operation time (WMD = 24.85 min; 95% CI: -3.01~52.78, P = 0.08), less intraoperative blood loss (WMD = -59.92 ml; 95% CI: -94.58~-25.27, P = 0.0007), similar hospital stays (WMD = -0.47 d; 95% CI: -1.78~0.83, P = 0.47), less postoperative complications (RR = 0.70, 95% CI: 0.51~0.94, P = 0.02), less analgesic use (SMD = -0.22; 95% CI: -0.44~-0.11, P = 0.04), similar transfusion rates (RR = 0.82; 95% CI: 0.24~3.12, P = 0.82), and similar graft weights (WMD = 7.31 g; 95% CI: -23.45~38.07, P = 0.64). CONCLUSION: Our results indicate that LADH is a safe and effective technique and, when compared to ODH.