Comparison of clinical outcome between laparoscopic and open hepatectomy of high difficulty score for hepatocellular carcinoma: a propensity score analysis.

BACKGROUND: Laparoscopic liver resection (LLR) of high difficulty score is technically challenging. There is a lack of clinical evidence to support its applicability in terms of the long-term survival benefits. This study aims to compare clinical outcomes between LLR and the open liver resection of high difficulty score for hepatocellular carcinoma (HCC). MATERIALS AND METHODS: From 2010 to 2020, using Iwate criteria, 424 patients underwent liver resection of high difficulty score by the laparoscopic (n = 65) or open (n = 359) approach. Propensity score (PS) matching was performed between the two groups. Short-term and long-term outcomes were compared between PS-matched groups. Univariate and multivariate analyses were performed to identify prognostic factors affecting survival. RESULTS: The laparoscopic group had significantly fewer severe complications (3% vs. 10.8%), and shorter median hospital stays (6 days vs. 8 days) than the open group. Meanwhile, the long-term oncological outcomes were comparable between the two groups, in terms of the tumor recurrence rate (40% vs. 46.1%), the 5-year overall survival rate (75.4% vs. 76.2%), and the 5-year recurrence-free survival rate (50.3% vs. 53.5%). The high preoperative serum alpha-fetoprotein level, multiple tumors, and severe postoperative complications were the independent poor prognostic factors associated with worse overall survival. The surgical approach (Laparoscopic vs. Open) did not influence the survival. CONCLUSION: LLR of high difficulty score for selected patients with HCC has better short-term outcomes than the open approach. More importantly, it can achieve similar long-term survival outcomes as the open approach.

Techniques of Laparoscopic Right Posterior Sectionectomy: Glissonian Approach and a Parenchymal Transection Technique.

Laparoscopic liver resections (LLR) have been widely accepted as a treatment option for liver tumors. They offer several advantages over open liver resections, including less blood loss, reduced wound pain, and shorter hospital stays with a comparable oncological outcome. However, laparoscopic resection of lesions in the right posterior section of the liver is challenging due to difficulties in bleeding control and visualizing the surgical field. In the past, laparoscopic right posterior sectionectomy (LRPS) was still in the exploration phase, with undefined risks in the Second International Consensus Conference on LLR in 2014. However, recent technological advancements and increased surgical experience have shown that LRPS can be safe and feasible. It has been found to reduce hospital stay and blood loss compared to open surgery. This manuscript aims to provide a detailed description of the steps involved in LRPS. The key factors contributing to our success in this challenging procedure include proper liver retraction and exposure, the use of an intrahepatic Glissonian approach for inflow control, a technique called the 'ultrasonic scalpel mimic Cavitron ultrasonic surgical aspirator (CUSA)' for parenchymal transection, early identification of the right hepatic vein, and meticulous bleeding control using bipolar diathermy.

Laparoscopic vs open liver re-resection for cirrhotic patients with post-hepatectomy hepatocellular carcinoma recurrence: A comparative study.

BACKGROUND: Repeated liver resection is an effective treatment for recurrent hepatocellular carcinoma (HCC). However, few studies have compared the outcome of laparoscopic repeat hepatectomy (LRH) and open repeat hepatectomy (ORH) for recurrent HCC, and few of those have included cirrhotic patients. AIM: To compare short-term and long-term outcomes of cirrhotic patients with LRH and ORH for recurrent HCC. METHODS: We retrospectively analysed the clinical records retrieved from a prospectively collected database of all patients who underwent hepatectomy for post-hepatectomy recurrent HCC at our institute between May 2006 and June 2021. Cases of recurrent HCCs larger than 7 cm were excluded. Patient demographics, operative details, perioperative outcomes, pathologic details, disease-free survival (DFS), and overall survival (OS) data of LRH and ORH were compared. RESULTS: Data from 29 patients with LRH and 22 with ORH were compared. The LRH group showed significantly better outcomes for blood loss (median 300 mL vs 750 mL, P = 0.013) and length of hospital stay (median 5 d vs 7 d, P = 0.003). The 1-, 3- and 5-year OS rates in the LRH group were 100.0%, 60.0% and 30.0%, respectively; the corresponding rates in the ORH group were 81.8%, 36.4% and 18.2% (P = 0.336). The 1-, 3- and 5-year DFS rates in the LRH group were 68.2%, 27.3% and 4.5%, respectively; the corresponding rates in the ORH group were 31.3%, 6.3% and 6.3% (P = 0.055). There were no significant differences in overall and DFS between the two groups. CONCLUSION: Laparoscopic re-resection should be considered for patients presenting with recurrent HCC less than or equal to 7 cm after previous hepatectomy.

Pure laparoscopic liver resection versus percutaneous radiofrequency ablation for small hepatocellular carcinoma: a propensity score and multivariate analysis.

Background: In treatment of hepatocellular carcinoma (HCC), both laparoscopic liver resection (LLR) and radiofrequency ablation (RFA) provided similar short-term advantages. However, there was no robust clinical trial comparing the efficacy of LLR and RFA especially for small HCC. This study aimed to compare the short-term and long-term outcomes of LLR and RFA for patients with small HCC using a propensity score matching analysis to minimize potential selection bias. Factors affecting survival were then identified with multivariate analysis. Methods: All patients underwent RFA or LLR for small HCC [defined as Barcelona Clinic Liver Cancer (BCLC) stage 0 or A, size ≤3 cm, ≤3 nodules on contrast CT scan or MRI with no evidence of macrovascular invasion] from April 2005 to August 2020 were included. Propensity score matching was conducted to match patients in the LLR group and RFA group. Prognostic indicators, i.e., age, gender, tumor size, tumor number, Child's grading, albumin, bilirubin, platelet count, international normalized ratio, alpha-fetoprotein level and presence of cirrhosis on imaging were chosen for propensity score calculation. The demographic data, tumor characteristics, operative data, post-operative outcomes and survival data of the two groups were compared. A multivariate analysis based on Cox regression was used to identify factors associated with survival. Results: Median follow-up was 34 months. LLR and RFA had similar overall survival (91.8% vs. 79.2% at 5-year, P=0.060); while the LLR had a significantly better disease-free survival (49.0% vs. 30.3% at 5-year, P=0.002) and local recurrence-free survival (96.0% vs. 63.7% at 5-year, P<0.001) when compared with the RFA. Multivariate analysis showed that treatment received by patient (LLR vs. RFA), prothrombin time and platelet counts were significantly associated with disease-free survival. On the other hand, the only factor associated with local recurrence-free survival was the treatment received by patient. Conclusions: Both RFA and LLR are safe and feasible treatment options for patients with small HCC. LLR should be considered for patients with preserved liver function with a better disease-free survival; while RFA offered a comparable overall survival with less surgical trauma and shorter hospital stay.

Laparoscopic hepatectomy versus open hepatectomy for hepatocellular carcinoma: A propensity case-matched analysis of the long-term survival.

BACKGROUNDS/AIMS: Despite the widespread popularity of laparoscopic surgery, laparoscopic liver resection (LLR) remains in evolution. This study aimed to compare the long-term outcomes for patients undergoing laparoscopic versus open hepatectomy for hepatocellular carcinoma (HCC) ≤7 cm. METHODS: Patients diagnosed with HCC treated by hepatectomy from October 2000 to May 2019 were included. Excluding tumors larger than 7 cm, 1:2 propensity score matching was performed between laparoscopic and open hepatectomies. The perioperative outcomes, 5-year overall survival (OS) and disease-free survival (DFS) of the two groups were compared. RESULTS: Forty-five patients who underwent LLR were matched to 90 open hepatectomy (OH) during the same period. LLR group had shorter median hospital stay (5 days vs. 9 days, p=0.00) but required longer operative time (326.0 minutes vs. 272.5 minutes, p=0.018) than the OH group. The 5-year overall survival was better in the LLR group (84.9% vs. 61.1%; p=0.036), though there was no significant difference in the 5-year disease free survival (20.0% vs. 22.2%, p=0.613). The rate of R0 resection was comparable between the 2 groups with a slightly better margin distance in the LLR (5 mm vs. 3 mm, p=0.043). CONCLUSIONS: Laparoscopic liver resection is safe and feasible for cirrhotic patients with HCC size up to 7 cm. It has better short-term outcomes and comparable perioperative blood loss and complication rates. The resection margin is not jeopardized and the 5-year overall and disease-free survivals are comparable with the open group.

Laparoscopic Caudate Lobectomy for Cholangiocarcinoma of Caudate Lobe Invading Middle Hepatic Vein.

BACKGROUND: Laparoscopic hepatectomy has gained popularity in the management of malignant liver lesions in the past decade. Its safety and feasibility, with faster recovery and comparable long-term outcomes, have been widely published. Nonetheless, laparoscopic isolated caudate lobectomy is still rare and technically demanding. We herein present a video on laparoscopic total caudate lobectomy for caudate cholangiocarcinoma. METHODS: The patient is a 61-year-old man who presented with epigastric distending discomfort. A contrast-enhanced magnetic resonance imaging was performed, showing a 4.6 × 3.9 cm tumor in the caudate lobe adjacent to the inferior vena cava, middle hepatic vein, right hepatic vein, as well as the bifurcation of the main trunk of the portal pedicle. The carbohydrate antigen was elevated to 54.58 U/ml (normal < 37 U/ml), and his liver function was normal. With the preoperative diagnosis of intrahepatic cholangiocarcinoma, laparoscopic caudate lobectomy was contemplated. RESULTS: The operative time was 300 min. The estimated intraoperative blood loss was 180 ml. The patient was discharged on the seventh postoperative day without any complications. Histopathological examination showed a 4.2 cm cholangiocarcinoma (T2N0M0) with a negative margin. He received a course of adjuvant chemotherapy. No recurrence was noted upon follow-up at 6 months after the operation. CONCLUSIONS: Laparoscopic resection for caudate lobe is a feasible and safe procedure. An experienced hepatobiliary surgeon could perform the procedure in selected cases, even with hepatic vein invasion.

Laparoscopic Anatomical Segment 2 Segmentectomy by the Glissonian Approach.

BACKGROUND: When hepatocellular carcinoma (HCC) was located in segment 2 (S2), segment-oriented hepatectomy was more beneficial than left lateral sectionectomy as this type of anatomical resection preserved the volume of the nontumor-bearing segment. Herein, we presented 2 cases (1 with video) of laparoscopic anatomical S2 segmentectomy by the Glissonian approach. METHODS: The first patient was a 69-year-old woman, who had an incidentally detected liver nodule on abdominal ultrasound for systemic surveillance for her breast cancer. The preoperative liver function was Child-Pugh class A. Abdominal computed tomography showed a 2 cm low attenuating lesion in S2. Contrast magnetic resonance imaging (MRI) showed the same lesion with features more suggestive of HCC. In view of the inconclusive imaging findings, a needle biopsy was performed and it confirmed the diagnosis of HCC. The second patient was a 57-year-old man with hepatitis B and Child-Pugh class B liver cirrhosis. He had an enlarging nonenhancing liver nodule in S2 noted on MRI. Laparoscopic anatomical S2 segmentectomy was performed for these 2 patients. RESULTS: The operative time for the first and second patients was 240 and 185 minutes, respectively. The respective estimated intraoperative blood loss was 50 and 250 mL and no transfusion was necessary. The patients were discharged on the fourth and fifth postoperative day without any complications, respectively. CONCLUSION: This study showed the feasibility of performing a laparoscopic S2 segmentectomy by the Glissonian approach.

Colonic self-expanding metal stent (SEMS) as a bridge to surgery in left-sided malignant colonic obstruction: an 8-year review.

INTRODUCTION: Colonic stenting has evolved to be an alternative to emergency laparotomy in the management of acute left-sided malignant colonic obstruction. This retrospective comparative study aimed to review the outcomes of colonic stent as bridge to surgery with emergency operation in a regional hospital in Hong Kong. METHOD: Consecutive patients who were admitted from January 2006 to July 2014 with diagnosis of malignant left-sided colonic obstruction (from splenic flexure to rectosigmoid colon) were included. Patients with peritonitis or disseminated disease were excluded. Colonic stenting was attempted in all eligible patients when fluoroscopy was available in the endoscopy suite during office hour. Otherwise, emergency operation was performed. For patients with clinical success in colonic stenting, interval colectomies were performed. The postoperative outcomes, including the 30-days mortality, the stoma creation rate, the complication rate as well as the survival data were analyzed on an intention-to-treat (ITT) basis. RESULTS: From January 2006 to July 2014, 62 patients underwent colonic stenting and 40 patients underwent emergency operations. The technical success rate and the clinical success rate of stenting were 95.2 and 83.9 %, respectively. Laparoscopic resection was achieved in 74.2 % in the stenting group. More primary anastomoses were performed in the stenting group (71.0 vs. 27.5 %, p = 0.000). The stenting group had a significantly lower permanent stoma rate (16.1 vs. 52.5 %, p < 0.000), fewer Dindo grade III to IV postoperative morbidity (16.1 vs. 40 %, p = 0.007), and the 30-day mortality rate was lower (3.2 vs. 17.5 %, p = 0.018), translating into a better overall 5-year survival rate. The disease-free survival was comparable between the two groups. CONCLUSIONS: Colonic self-expanding metal stent is effective in the management of acute left-sided colonic obstruction. It is associated with reduced stoma creation rate and postoperative morbidity. The oncological safety is not jeopardized by stenting and the interval operation.

Laparoscopic Total Caudate Lobectomy for Hepatocellular Carcinoma.

BACKGROUND: Caudate lobe is located in the deep dorsal area of the liver between the portal triad and the inferior vena cava (IVC). Torrential bleeding can occur from the IVC and short hepatic veins during dissection. Isolated total caudate lobe resection is still rare and technically demanding. We herein present a video on the technical aspect of laparoscopic total caudate lobectomy. METHOD: A 61-year-old woman was admitted for recurrent hepatocellular carcinoma detected on imaging. She had history of multifocal hepatocellular carcinoma in July 2015 and underwent open cholecystectomy, segment 6 and segment 8 tumorectomy. Ten months later, the computed tomography scan and magnetic resonance imaging showed a 1 cm arterial enhancing lesion in segment I (S1) with no other foci of recurrence. Laparoscopic total caudate lobectomy was contemplated. RESULTS: The operative time was 270 minutes. The intraoperative blood loss was 200 mL and blood transfusion was not necessary. The patient was discharged on the fourth postoperative day without any complications. CONCLUSION: This report showed the safety and feasibility of laparoscopic total caudate lobectomy. Nonetheless, it is a technically demanding procedure. It should be performed in carefully selected patients and by experienced hepatobiliary surgeons proficient in laparoscopic liver resection.

Learning Curve for Laparoscopic Major Hepatectomy: Use of the Cumulative Sum Method.

BACKGROUND: Laparoscopic liver resection (LLR) has now become a worldwide practice. However, the adoption of laparoscopic major hepatectomy (LMH) was slow. We report our center's experience in laparoscopic major resections. METHOD: A total of 156 LLRs from 2002 to 2014 were studied. The clinical parameters of LMHs were compared with those of minor resections. The learning curve of LMHs was investigated using the cumulative sum (CUSUM) analysis of operative time. Subgroup analysis of right posterior sectionectomies against anterolateral hepatectomies was conducted. RESULTS: Among the 156 LLRs, 49 (31%) were LMHs. CUSUM analysis showed that operative time improved after the 25th LMH. Beyond that proportion of pure laparoscopic LMHs increased (18/25 vs. 24/24, P=0.005); Pringle maneuver was not required (4/25 vs. 0/24, P=0.041). Blood loss (800 vs. 500 mL, P=0.034) and transfusion rate (13/25 to 3/24, P=0.003) improved in latter LMHs. Right posterior sectionectomies had significantly more blood loss than anterolateral LMHs (500 vs. 1500 mL, P=0.034). CONCLUSION: Laparoscopic major resection is safe and feasible; operative outcomes improved after overcoming the learning curve. Right posterior sectionectomy, however, should be further evaluated for its cost-effectiveness.

Laparoscopic Right Posterior Sectionectomy for Malignant Lesions: An Anatomic Approach.

BACKGROUND: Good indications for laparoscopic hepatectomy are still considered to be tumors located over anterolateral segments of the liver. Tumors located over the right posterior section are considered to be difficult for laparoscopic resection. In this case series, we present our experience on laparoscopic right posterior sectionectomy. PATIENTS AND METHODS: All patient data were prospectively collected. Data on patient demographics, tumor characteristics, operative data, and postoperative outcome were collected and analyzed. RESULTS: During the period of May 2010-May 2014, we performed 13 laparoscopic right posterior sectionectomies. The diagnoses were hepatocellular carcinoma in 11 patients, of which 2 were cases of colorectal liver metastasis. Median operative time was 381 minutes, and median blood loss was 1500 mL. Significant bleeding occurred in the first 5 patients. The median size of the tumor resected was 3.7 cm, and the median resection margin was 8.7 mm. Four of the 13 patients (30.8%) were cirrhotic on histological examination. There was no postoperative mortality. Median hospital stay was 7 days. CONCLUSIONS: Laparoscopic right posterior sectionectomy is technically demanding. A proper inflow and outflow control is mandatory for proper anatomical resection. This surgical principle should not be compromised in the era of laparoscopic hepatectomy.