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.

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.

Laparoscopic anatomic monosegmentectomy of hepatocellular carcinoma of the right hepatic lobe.

PURPOSE: Laparoscopic resection of lesions at right hepatic lobe is considered difficult. The objective of this study is to describe our institutional techniques of laparoscopic anatomic monosegment resection of hepatocellular carcinoma (HCC) in all segments of the right lobe. METHODS: Patients with deep-seated solitary tumors in a single segment of right hepatic lobe were considered for laparoscopic anatomic monosegment resection when the planned transection plane could give a 1-cm resection margin from the adjacent nontumour segments. The purpose of this surgery design is to achieve an oncologic resection while preserving the maximal volume of liver parenchyma. RESULTS: Five patients underwent successful laparoscopic anatomic monosegmentectomy with no conversion to open. They were all male with a solitary HCC size ranging from 2 to 3 cm. Cirrhosis was present in 2 (40%) patients. The mean blood loss was 676 mL (range, 280 to 1200 mL) and perioperative blood transfusion was not required. There was no operative mortality or morbidity, and no recurrences were noted. CONCLUSIONS: Laparoscopic monosegmentectomy is feasible and safe in selected patients with HCC. It provides the benefit of maximal preservation of nontumour liver parenchyma, while oncologic resection is secured.

Optimal timing of elective laparoscopic cholecystectomy after acute cholangitis and subsequent clearance of choledocholithiasis.

BACKGROUND: Elective laparoscopic cholecystectomy is recommended after endoscopic clearance of choledocholithiasis for patients with acute cholangitis, according to Tokyo guidelines. However, the optimal timing remains uncertain. METHODS: Perioperative outcomes were retrospectively reviewed and compared between patients with early (< 6 weeks) and late (> 6 weeks) surgeries, while risk factors for postoperative complications were assessed using multivariate analysis. RESULTS: One hundred twelve patients (mean age, 64 years; range, 30-85 years) were analyzed. Rate of conversion and intraoperative and postoperative complications (classified per Dindo et al) were 21.4% (24 of 112), 23.2% (26 of 112), and 34.8% (39 of 112), respectively. The late surgery group had significantly more intraoperative (28.8% vs 9.4%, P = .029) and postoperative (42.5% vs 15.6%, P = .007) complications compared with the early surgery group. Multivariate analysis showed both late surgery (95% confidence interval, 1.47-12.5; P = .008) and a history of endoscopic sphincterotomy (95% confidence interval, 1.06-8.26; P = .038) to be independent risk factors for postoperative complications. CONCLUSIONS: Patients with endoscopic clearance of choledocholithiasis, especially after endoscopic sphincterotomy, should receive elective laparoscopic cholecystectomy within 6 weeks after a cholangitic attack.

Hepatectomy for hepatocellular carcinoma in a community hospital: the importance of surgeon procedural volume in operative outcomes.

BACKGROUND/AIMS: Hospital procedural volume is shown to be important in affecting the postoperative mortality after major cancer surgery. Recent analysis demonstrates that hospital and surgeon volume effects on postoperative outcomes after major operations are actually interdependent and surgeon volume may be more important. The effects of hospital and surgeon volume on postoperative outcomes after hepatectomy for hepatocellular carcinoma are uncertain. METHODOLOGY: A retrospective study was conducted of 65 patients who had undergone hepatectomy for hepatocellular carcinoma in a 6-year period. A specialized hepatobiliary team was set up in 2002 in the Kwong Wah Hospital. The postoperative outcomes of patients operated between 1999 and 2001 (Group 1) were compared to that of those treated between 2002 and 2004 (Group 2). RESULTS: The hospital mortality was 8.3% in Group 1 and 3.4% in Group 2 (p = 0.393). The postoperative morbidity was 50% in Group 1 but decreased to 27.6% in Group 2, though the difference was not statistically significant (p = 0.056). The median hospital stay of patients in Group 2 was significantly shorter than that of those in Group 1 (17 days vs. 11 days, p = 0.005). CONCLUSIONS: Despite the unchanged hospital volume, concentration of patients into a single team increases surgeon volume and improves postoperative outcomes after hepatectomy for hepatocellular carcinoma.

Primary hepatic carcinoid tumour: a detailed account of imaging findings.

Primary hepatic carcinoid tumours are very rare and less than 60 cases have been reported in the literature. This study reports a 35-year-old female with 2 synchronous primary hepatic carcinoid tumours in her right hepatic lobe. She was examined with various imaging investigations including ultrasound scan, computed abdominal tomography, magnetic resonance imaging, mesenteric angiography and positron emission tomography. She underwent right hepatectomy and the lesions were proven to be carcinoid tumours. She has been free of disease for more than 5 years of follow-up and the diagnosis of primary hepatic carcinoid tumour is suggested.

Delayed colonic perforation after percutaneous radiofrequency ablation of hepatocellular carcinoma.

Radiofrequency ablation (RFA) is an effective treatment for hepatocellular carcinoma. Colonic perforation secondary to RFA of the liver is an uncommon complication that has been reported to have an incidence between 0.1% and 0.3%. Lesions adjacent (within 1 cm) to the colonic wall and those in patients with history of upper abdominal surgery or chronic cholecystitis are particularly at risk. More importantly, thermal injury leading to colonic perforation has proved to have a fatal outcome. We present a case of percutaneous RFA in a patient with hepatocellular carcinoma that was abutting the colonic hepatic flexure. Colonic perforation was diagnosed on the eighth day postablation when the patient was readmitted with peritonitis.

APACHE system is better than Ranson system in the prediction of severity of acute pancreatitis.

BACKGROUND: It has been suggested that addition of obesity score to the APACHE-II system can lead to more accurate prediction of severity of acute pancreatitis. However there is scanty information on the usefulness of the combined APACHE-O scoring system in Asian patients. This study aimed to compare the accuracy of Ranson, APACHE-II and APACHE-O systems in assessing severity of acute pancreatitis in a local Chinese population. METHODS: One hundred and one consecutive patients with acute pancreatitis were prospectively studied. Body mass index (BMI) was measured on admission. Ranson score, APACHE-II and APACHE-O scores were recorded on admission and at 48 hours. By adopting the cut-off levels and definitions advocated in the Atlanta consensus for severe disease, the diagnostic accuracy of the three scoring systems was compared by the area under the curve (AUC) under the receiver operator characteristic curve. RESULTS: Of the 101 patients, 12 (11.9%) patients suffered from severe pancreatitis. Obesity was uncommon and only two patients (2.0%) had BMI>30. Eighty-two (81.2%) patients were normal weight (BMI< or =25) whereas 17 (16.8%) were overweight (BMI 25-30). Overweight or obesity (BMI>25) was not associated with severe pancreatitis (P=0.40). The AUC for admission scores of Ranson, APACHE-II, and APACHE-O systems was 0.549, 0.904 and 0.904, respectively. The AUC for 48-hour scores of Ranson, APACHE-II and APACHE-O systems was 0.808, 0.955 and 0.951, respectively. CONCLUSIONS: The APACHE-II scoring system is more accurate than the Ranson scoring system of the prediction of severity in acute pancreatitis. Addition of obesity score does not significantly improve the predictive accuracy of the APACHE-II system in our local population with a low prevalence of obesity.

Natural history of untreated nonsurgical hepatocellular carcinoma.

OBJECTIVE: Hepatocellular carcinoma (HCC) is common in Asia, and the majority are not suitable for curative surgical treatment. We studied the natural history of untreated nonsurgical HCC to examine whether the prognosis has changed with improved supportive treatment and to identify factors affecting survival. METHODS: One hundred and six ethnic Chinese patients with HCC not amenable to curative treatment were managed symptomatically as control-arm patients in three randomized studies conducted between January 1996 and April 2001. Seventy-six (71.7%) patients were positive for hepatitis B surface antigen (HBsAg). Prognostic variables for survival were identified by univariate analysis and were subjected to a multivariate Cox analysis to identify the independent predictors of survival. RESULTS: All but four patients were followed until death. Common causes of death were tumor progression (63.2%) and liver failure (31.1%). The overall median survival was 3 months, and the 1-yr survival was 7.8% only. The median survival of patients of Okuda stages I, II, and III were 5.1 months, 2.7 months, and 1.0 month, respectively (p < 0.05 for comparison between any two stages). Multivariate analysis revealed four independent prognostic variables, namely, serum bilirubin, blood urea, serum alpha-fetoprotein, and Okuda stage. CONCLUSIONS: The prognosis of untreated HCC not suitable for curative treatment in Asia is grave despite improved supportive treatment. The four prognostic variables identified in this study are important in the decision for palliative treatment, and the Okuda staging remains an important prognostic guide.

Biliary papillomatosis: report of seven cases and review of English literature.

Biliary papillomatosis is rare. Before 1993, there were only 21 cases reported in the English literature. This article reports our experience in managing this disease and reviews experiences from recent English literature. A retrospective review of patients with biliary papillomatosis was conducted in our institution. A search of the English literature between 1993 and 2002 was performed in the MEDLINE database using "biliary papillomatosis" as the keyword. Seven patients with biliary papillomatosis were treated in our hospital. Another 50 cases were reported in the recent literature. This amounted to a total of 78 cases so far reported. The male to female ratio was approximately 2 : 1. The mean age at presentation was 63 years. Most patients presented typically with cholangitis. Malignant change was present in 33 patients (42%). Concomitant intrahepatic and extrahepatic disease was noticed in 33 patients (42%). The overall resection rate was 55%. The mean survival was 28 months following resection, irrespective of histological type. Patients without tumor resection had a poorer survival of less than 11 months. Biliary papillomatosis presents typically with biliary obstruction and it occurs most often in elderly males. Resection is recommended because of the considerable malignancy rate, diffuse pattern of disease, and better survival following curative surgery. Malignant histology is not always associated with a poorer prognosis provided that radical resection can be achieved.

Role of ERCP in the management of predicted mild acute biliary pancreatitis.

OBJECTIVE: The role of endoscopic retrograde cholangiopancreatography (ERCP) in mild acute biliary pancreatitis is controversial. This study examined the results of ERCP in patients with predicted mild disease and analysed biochemical and imaging findings in relation to the occurrence of choledocholithiasis. PATIENTS AND METHODS: There were 172 consecutive patients, admitted between January 1998 and December 2000, with the diagnosis of acute pancreatitis. All patients were investigated using transcutaneous ultrasonography and ERCP if biliary aetiology was suspected. Serum bilirubin and alkaline phosphatase were measured, together with abdominal ultrasonographic findings, as potential predictors for choledocholithiasis. RESULTS: Biliary calculus was the aetiology in 62.8% of patients (108/172). Among these 108 patients, 79.6% (86/108) suffered from mild disease. There were only 80 patients who underwent ERCP, and the incidence of choledocholithiasis was 45% (36/80). Although significant correlation was shown between all three measured parameters (bilirubin, alkaline phosphatase and ultrasonographic abnormalities) and choledocholithiasis, their individual sensitivities, specificities and predictive values were low. Nonetheless, if all three tests were normal, the incidence of ductal stones was significantly lower than that in cases with abnormalities in any one of these parameters (4.8% vs 59.3%). CONCLUSION: Routine ERCP is not recommended for patients with mild, acute biliary pancreatitis when there is no biochemical derangement or ultrasonographic evidence of a dilated biliary system.