Outcomes of major laparoscopic liver resection for hepatocellular carcinoma.

BACKGROUND: To compare the surgical outcomes of major laparoscopic liver resection (LLR) and open liver resection (OLR) for hepatocellular carcinoma (HCC). METHODS: We retrospectively reviewed the medical records of 177 patients who underwent major liver resection for HCC between January 2004 and June 2015. We divided the 177 patients into two groups according to the type of procedure: major LLR (LLR group; n = 67) and major OLR (OLR group; n = 110). RESULTS: Procedures in the LLR group were right hepatectomy (30 patients), right posterior sectionectomy (28), left hepatectomy (11), right anterior sectionectomy (6), extended right hepatectomy (6), and central bisectionectomy (2). Tumor size was greater in the OLR group than in the LLR group (6.3 ± 3.8 vs 4.1 ± 2.4 cm; P = 0.016). The mean indocyanine green retention rate at 15 min (P = 0.698) and serum α-fetoprotein (P = 0.186) were similar in both groups. The mean operation time was longer in the LLR group (416.6 ± 166.9 vs 332.5 ± 105.4 min; P = 0.002). Blood loss (P = 0.319), transfusion rate (P = 0.260), and R0 rate (P = 0.255) were similar in both groups. Hospital stay was shorter (11.3 ± 8.3 vs. 18 ± 21.4 days; P = 0.007) and the complication rate was lower (20.5% vs. 38.7%; P = 0.005) in the LLR group. The 5-year overall survival (77.3% vs 60.2%; P = 0.087) and disease-free survival (50.8% vs 40.1%; P = 0.139) rates were comparable in both groups. CONCLUSION: Major LLR of HCC is feasible and oncologically safe when performed by experienced surgeons. Further refinements of the surgical technique are needed to reduce operation time.

Comparative Performance of the Complexity Classification and the Conventional Major/Minor Classification for Predicting the Difficulty of Liver Resection for Hepatocellular Carcinoma.

OBJECTIVE: To compare performances for predicting surgical difficulty and postoperative complications. BACKGROUND: An expert panel recently proposed a complexity classification for liver resection with 3 categories of complexity (low, medium, or high). We compared this new classification with the conventional major/minor classification. METHODS: We retrospectively reviewed 469 hepatocellular carcinoma patients who underwent liver resection between 1 January 1, 2004 and June 30, 2015. We used receiver-operating characteristic curve analysis to compare the performances of both classifications for predicting perioperative outcomes. RESULTS: Both classifications effectively differentiated subgroups of patients in terms of their intraoperative findings and short-term outcomes, including blood loss, transfusion rate, operation time, and postoperative hospital stay (all P < 0.05). The ability to predict complications was not significantly different between the major/minor classification and the complexity classification [area under the curve (AUC) 0.625 vs 0.617, respectively; P= 0.754). However, the complexity classification showed stronger correlations with blood loss (AUC 0.690 vs 0.617, respectively; P = 0.001) and operation time (AUC 0.727 vs 0.619, respectively; P < 0.001) compared with the major/minor classification. To check heterogeneity, the minor resection group was further divided into low (n = 184), medium (n = 149), and high complexity (n = 13) groups. Operation time and blood loss were significantly different among these 3 subgroups of patients. CONCLUSIONS: The complexity classification outperformed the major/minor classification for predicting the surgical difficulty of liver resection.

Laparoscopic liver resection of hepatocellular carcinoma located in segments 7 or 8.

BACKGROUND: Many centers consider hepatocellular carcinoma (HCC) located in segments 7 or 8 to be unsuitable for laparoscopic liver resection (LLR). We evaluated the safety of LLR of HCC in segments 7 or 8 following the introduction of new laparoscopic techniques. METHODS: This retrospective study included 104 patients who underwent LLR (n = 46) or open liver resection (OLR) (n = 58) for HCC located in segments 7 or 8 between October 2004 and June 2015. The LLR group was subdivided into two subgroups according to whether LLR was performed before (Lap1; n = 29) or after (Lap2; n = 17) the introduction of the Pringle maneuver, intercostal trocars, and semi-lateral patient positioning. RESULTS: Non-anatomical resection was more frequent (63.0 vs. 29.3%; P < 0.001) and tumor size was smaller (2.8 vs. 4.7 cm; P < 0.001) in the LLR group than in the OLR group. Blood transfusion (P = 0.526), operation time (P = 0.267), postoperative complications (P = 0.051), and resection margin (P = 0.705) were similar in both groups. LLR was associated with less blood loss (550 vs. 700 ml, P = 0.030) and shorter hospital stay (8 vs. 10 days; P = 0.001). The 3-year overall (90.2 vs. 81.2%, P = 0.096) and disease-free survival (15.1 vs. 12.1%; P = 0.857) rates were similar in both groups. The Lap2 group has less blood loss (230 vs. 500 ml; P = 0.005) and shorter hospital stay (7 vs. 9 days; P = 0.038) compared with the Lap1 group. CONCLUSION: LLR can be safely performed for HCC located in segments 7 or 8 with recent improvements in surgical techniques and accumulated experience.

Multidisciplinary management of intrahepatic cholangiocarcinoma: Current approaches.

Intrahepatic cholangiocarcinoma (ICC) is a common primary hepatic tumor. However, its outcomes are usually worse than those of hepatocellular carcinoma owing to its non-specific presentation and detection at an advanced stage. The most widely used serum marker, carbohydrate antigen 19-9, is non-specific. Furthermore, imaging studies rarely identify any pathognomonic features. Surgery is the only treatment option that offers a chance of long-term survival. However, the resectability rate is low owing to the high frequencies of intrahepatic metastases, peritoneal carcinomatosis, or extrahepatic metastases. Surgical treatment should be tailored according to the macroscopic classification of ICC (e.g. mass-forming, periductal infiltrating, and intraductal growth types) because it reflects the tumor's dissemination pattern. Although lymph node metastasis is a negative prognostic factor, the importance and extent of lymph node dissection is still controversial. To improve patient survival, liver transplantation is considered in some patients with unresectable ICC, especially in those with an insufficient remnant liver volume. Minimally invasive procedures, including laparoscopic and robotic liver resection, have been tested and achieved comparable outcomes to conventional surgery in preliminary studies. No randomized trials have confirmed the efficacy of adjuvant chemotherapy in ICC, and several trials have evaluated molecular-targeted agents as monotherapy or in combination with cytotoxic chemotherapy. Multidisciplinary approaches are necessary to improve the outcomes of ICC.

Prediction of surgical outcomes of laparoscopic liver resections for hepatocellular carcinoma by defining surgical difficulty.

BACKGROUND: Several classification systems for assessing the surgical difficulty of laparoscopic liver resection (LLR) have been proposed. We evaluated three current classification systems, including traditional Major/Minor Classification, Complexity Classification, and the Difficulty Scoring System for predicting the surgical outcomes after LLR. METHODS: We reviewed the clinical data of 301 patients who underwent LLR for hepatocellular carcinoma between March 1, 2004 and June 30, 2015. We compared the intraoperative, pathologic, and postoperative outcomes according to the three classifications. We also compared the prognostic value of the three classifications using receiver operating characteristic (ROC) curves. RESULTS: The Major/Minor Classification, Complexity Classification, and the Difficulty Scoring System efficiently differentiated surgical difficulty in terms of blood loss (P = 0.001, P = 0.009, and P < 0.001, respectively) and operation time (all P < 0.001). Regarding intraoperative outcomes, the Difficulty Scoring System and Complexity Classification successfully differentiated the transfusion rate (P = 0.001 and P < 0.001, respectively). However, only the Complexity Classification adequately predicted severe postoperative complications (P = 0.032), the severity of complications (P < 0.001), and the length of hospital stay (P = 0.005). In ROC curve analysis, the Complexity Classification (area under the curve [AUC] = 0.611) outperformed the Major/Minor Classification (AUC = 0.544) and the Difficulty Scoring System (AUC = 0.530) for predicting severe postoperative complications. None of the classification systems predicted recurrence or patient survival. CONCLUSION: The Complexity Classification was superior to the other methods for assessing surgical difficulty and predicting complications after LLR for hepatocellular carcinoma.

Current status of laparoscopic liver resection for hepatocellular carcinoma.

Laparoscopic liver resection (LLR) is becoming widely accepted for the treatment of hepatocellular carcinoma (HCC). Laparoscopic left lateral sectionectomy and minor laparoscopic liver resection are now considered standard approaches, especially for tumors located in the anterolateral segments of the liver. Laparoscopic left lateral sectionectomy in adult donors is also gaining acceptance for child liver transplantation in many centers. Major LLRs, including left hepatectomy and right hepatectomy, have been recently attempted. Laparoscopic donor hepatectomy is becoming more popular owing to increasing demand from young living donors who appreciate its minimal invasiveness and excellent cosmetic outcomes. Several centers have performed total laparoscopic donor right hepatectomy in adult-to-adult living donor liver transplantation. Many meta-analyses have shown that LLR is better than open liver resection in terms of short-term outcomes, principally cosmetic outcomes. Although no randomized control trials have compared LLR with open liver resection, the long-term oncologic outcomes were similar for both procedures in recent case-matched studies.