Oncological efficiency analysis of laparoscopic liver resection for primary and metastatic cancer: a single-center UK experience.

OBJECTIVE: To assess the oncological efficiency of laparoscopic minor and major hepatectomy for primary and metastatic liver malignant neoplasms. DESIGN: Retrospective single-center study. SETTING: Tertiary university hospital. PATIENTS: One hundred twenty-eight patients undergoing 133 laparoscopic liver resections for malignant diseases. MAIN OUTCOME MEASURES: Perioperative results and midterm overall and disease-free survival. RESULTS: Surgical indications were colorectal carcinoma liver metastasis (n = 83), hepatocellular carcinoma (n = 18), neuroendocrine tumor metastasis (n = 17), non-colorectal carcinoma liver metastasis (n = 11), lymphoma (n = 2), and intrahepatic cholangiocarcinoma (n = 2). Two patients had 2-stage laparoscopic resections for bilobar colorectal carcinoma liver metastasis. Three patients had repeated liver resection for recurrent colorectal carcinoma liver metastasis. Forty-two major hepatectomies (32%) were performed. The median operative time was 210 minutes (range, 30-480 minutes). The median postoperative length of stay was 4 days (range, 1-15 days). Seven patients required conversion to formal open surgery and 4 patients required conversion to a laparoscopic-assisted procedure. Sixteen patients (13%) developed significant postoperative complications. One patient (0.8%) died in the hospital. In the 17 patients with neuroendocrine tumor metastasis, 6 (35%) had microscopic positive resection margins. Most of these patients underwent debulking and cytoreductive surgery. A microscopic negative resection margin was obtained in the remaining 112 of 116 resections (97%). We recorded 2-year overall survivals of 80%, 77%, and 91% in the groups with colorectal carcinoma liver metastasis, hepatocellular carcinoma, and neuroendocrine tumor metastasis, respectively. CONCLUSIONS: Our data support the safety and oncological efficiency of laparoscopic resection for liver malignant neoplasms. Adequate patient selection and extensive experience in hepatic and laparoscopic surgery are essential prerequisites to optimize outcomes.

Laparoscopic liver resection for hepatocellular adenoma.

AIM: To investigate the role of laparoscopy in the surgical management of hepatocellular adenoma (HA). METHODS: We reviewed a prospectively collected database of consecutive patients undergoing laparoscopic liver resection for HA. RESULTS: Thirteen patients underwent fifteen pure laparoscopic liver resections for HA (male/female: 3/10; median age 42 years, range 22-72 years). Two patients with liver adenomatosis required two different laparoscopic operations for ruptured adenomas. Indications for surgery were: symptoms in 12 cases, need to rule out malignancy in 2 cases and preoperative diagnosis of large HA in one case. Symptoms were related to bleeding in 10 cases, sepsis due to liver abscess following embolization of HA in one case and mass effect in one case (shoulder tip pain). Five cases with ruptured bleeding adenoma required emergency admission and treatment with selective arterial embolization. Laparoscopic liver resection was then semi-electively performed. Eight patients (62%) required major hepatectomy [right hepatectomy (n = 5), left hepatectomy (n = 3)]. No conversion to open surgery occurred. The median operative time for pure laparoscopic procedures was 270 min (range 135-360 min). The median size of the excised lesions was 85 mm (range 25-180 mm). One patient with adenomatosis developed postoperative bleeding requiring embolization. Mortality was nil. The median hospital stay was 4 d (range 1-18 d) with a median high dependency unit stay of 1 d (range 0-7 d). CONCLUSION: The laparoscopic approach represents a safe option for the management of HA in a semi-elective setting and when major hepatectomy is required.

Laparoscopic right hepatectomy: a challenging, but feasible, safe and efficient procedure.

BACKGROUND: Few centers are undertaking major laparoscopic liver resections, because of the well-recognized technical difficulties and lack of training opportunities. METHODS: The authors describe their technique for laparoscopic right hepatectomy, highlighting relevant details for accomplishing a safe and efficient procedure. Patients were chronologically divided into 2 groups to evaluate the impact of increasing experience on the surgical outcomes. RESULTS: Group I included 17 patients and group II 18 patients. The conversion rate to open or hybrid techniques significantly decreased from 36% in group I to 6% in group II (P = .03). The hospital stay decreased from a median of 6 days in group I to a median of 4 days in group II (P = .05). Complications occurred in 4 patients (11%), of whom 3 were in group I. The mortality was zero. CONCLUSIONS: Laparoscopic right hepatectomy is a safe and efficient procedure when performed at specialized centers with extensive experience in hepatic surgery. Long-term training is necessary to acquire adequate expertise.

Pure laparoscopic en bloc left hemihepatectomy and caudate lobe resection in patients with intrahepatic cholangiocarcinoma.

INTRODUCTION: There is an ongoing debate on whether it is safe to push the boundaries and widen the indications of laparoscopic liver surgery after careful patient selection. We report 2 cases of pure laparoscopic en bloc left hemihepatectomy and caudate lobe resection for intrahepatic cholangiocarcinoma (ICC). METHODS: The first patient (a 79-year old) had an ICC affecting segments 2, 3, and 4 of the liver with dilatation of segment 1 ducts at preoperative imaging. The second patient (an 81-year old) had an ICC affecting segments 2, 3 with local invasion of segment 1. Both patients underwent pure laparoscopic left hemihepatectomy and caudate lobe resection. RESULTS: The first patient's operative time was 360 minutes and blood loss was 390 mL. Postoperative hospital stay was 8 days. The definitive histology was as follows: pT1 ICC (25 mm in maximal diameter), with 20 mm free resection margin. The second patient's operative time was 310 minutes and blood loss was 300 mL. Postoperative hospital stay was 4 days. The definitive histology was as follows: T1 ICC (49 mm in maximal diameter) with 10 mm free resection margin. The first patient was disease free 12 months after surgery. The second patient died 11 months after surgery of metastatic disease. CONCLUSION: Pure laparoscopic left hemihepatectomy and caudate lobectomy for ICC may be feasible and safe. This is, however, a very complex procedure requiring extensive experience in laparoscopic liver surgery and careful patient selection to optimize surgical outcome. To our knowledge, this is the first systematic description of a pure laparoscopic en bloc left hemihepatectomy and caudate lobe resection for ICC.

Surgical management of benign and indeterminate hepatic lesions in the era of laparoscopic liver surgery.

BACKGROUND/AIMS: The expansion of the laparoscopic approach for the management of benign liver lesions has raised concerns regarding the risk of widening surgical indications and compromising safety. Large single-centre series focusing on laparoscopic management of benign liver lesions are sporadic. METHODS: We reviewed a prospectively collected database of patients undergoing pure laparoscopic liver resection (LLR) for benign liver lesions. All cases were individually discussed at a multidisciplinary team meeting. RESULTS: Forty-six patients underwent 50 LLRs for benign disease. Indications for surgery were: symptomatic lesions, preoperative diagnosis of adenoma or cystadenoma, and lesions with an indeterminate diagnosis. The preoperative diagnosis was uncertain in 11 cases. Of these, histological diagnosis was hepatocellular carcinoma in one (9%) and benign lesion in 10 patients (91%). Thirteen patients (28%) required major hepatectomy. Three patients (7%) developed postoperative complications. Mortality was nil. The median postoperative hospital stay following major and minor hepatectomy was 4 and 3 days, respectively. CONCLUSION: The laparoscopic approach represents a safe option for the management of benign and indeterminate liver lesions, even when major hepatectomy is required. LLR should be only performed in specialized centres to ensure safety and strict adherence to orthodox surgical indication.

Single-centre comparative study of laparoscopic versus open right hepatectomy.

BACKGROUND: Expansion of laparoscopic major hepatectomy is still limited mainly due to the well-recognised technical difficulties compared to open surgery, and doubts regarding the oncological efficiency when major resections are required. METHODS: Patients undergoing open right hepatectomy (ORH) were matched with patients undergoing laparoscopic right hepatectomy (LRH) and compared for perioperative outcomes. RESULTS: Seventy patients were included: 36 patients underwent LRH and 34 ORH. Operative time was significantly longer for LRH (median, 300 min vs. 180 min for ORH; p < 0.0001). Intensive care unit (median, 2 days for LRH vs. 4 days for ORH; p < 0.0001) and postoperative length of stay (5 days for LRH vs. 9 days for ORH; p < 0.0001) were significantly shorter for LRH. Four laparoscopic cases were converted to open surgery. No significant difference in postoperative complications and mortality was observed between LRH and ORH. Among patients with colorectal carcinoma liver metastases, R0 resection was obtained in 20/21 (95%) cases after LRH, and in 20/25 (80%) after ORH (p = 0.198). Mid-term overall survival did not significantly differ between the laparoscopic and the open group. CONCLUSIONS: LRH can be a safe, effective, and oncologically efficient alternative to open resection in selected cases. Extensive experience in hepatic and laparoscopic surgery is required.

Obstructive chronic pancreatitis and/or intraductal papillary mucinous neoplasms (IPMNs): a 21-year long case report.

CONTEXT: Intraductal papillary mucinous neoplasms of the pancreas (IPMNs), usually present with a picture of chronic pancreatitis and must be considered within the differential diagnosis of this condition. CASE REPORT: We report a long history of a 58-year-old male who presented with recurrent attacks of pancreatitis. He was treated for chronic pancreatitis until the age of 78 when the diagnosis of IPMN was made, but radical treatment was not possible and he was managed palliatively. The patient died of sepsis and multi-organ failure 21 years following his first presentation. CONCLUSION: This case highlights possible pitfalls in the diagnosis and treatment of IPMNs, suggests a very long natural history, proposes possible palliative treatment in selected cases and reflects about IPMNs biological position in the chronic pancreatitis-ductal adenocarcinoma chain.