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105
DWI characteristics improved the sensitivity of conventional MRI from 83–85 % to
98 % in detecting HCC lesions <2 cm [ 60 ]. Furthermore, several studies that
assessed the impact of combining HBP imaging with DWI to detect HCC concluded
that DWI can incrementally improve the performance of MRI in the detection of
HCC (Table 9.5 ) [ 61 – 63 ]. While these techniques are promising, the optimal inter-
val of imaging and the cost of such a screening tool have not been examined.
Therefore, evidence supporting the use of MRI for the screening and surveillance of
cirrhotics for HCC is lacking, and their use has not been incorporated in the current
practice guidelines.
Recommendations
While the clinical effectiveness of screening individuals with cirrhosis has yet to be
determined, indirect evidence supports a survival benefi t with screening of targeted
individuals who are viable candidates for interventions. Biannual ultrasound with or
without serum AFP is the most validated tool, offers good performance in the
general population, and in experienced hands likely has similar performance to
triple phase MDCT for the detection of tumors >2 cm. However, as locoregional
therapy becomes more widely available, the detection of early HCC may offer a
survival benefi t. In this context, dynamic MRI with hepatobiliary phase and diffusion weighted imaging may be the best-performing screening test. Screening,
regardless of modality, should be done in expert hands to optimize effectiveness of
the test. The cost of such a surveillance program will have to be compared to its
clinical effectiveness, which is largely dependent on uptake of screening and linkage to treatment.
A Personal View of the Data
Many advances have been made in the diagnosis of HCC over the past decade.
Improvements in CT and MRI technology form the basis of this progress; however,
translation into clinical practice and guidelines is limited by the quality of data
supporting their use in screening and surveillance programs. Current data have
created a strong platform for imaging-based screening of HCC, whereas the importance of tumor markers and invasive method such as biopsy has declined. In an era
where the morbidity and mortality associated with HCC is rising, efforts to improve
early diagnosis must be made in order to impact patient outcomes and reduce the
healthcare burden associated with HCC. In this context, MRI-based imaging has the
most promise for accuracy, although its cost is a major deterrence in its use as the
fi rst line tool.
9 What Is the Best Way to Screen Cirrhotic Patients for Hepatocellular Carcinoma…
106
Table 9.5 Summary of studies of the performance of gadoxetic acid-enhanced MRI with or without DWI in the detection of HCC
Study Imaging method Cohort Sensitivity Specifi city Clinical performance
Study type (Quality of
evidence)
Park et al.
[
63 ]
Gadoxetic acid-
enhanced MRI with
or without DWI at
3.0-T as reviewed by
three independent,
blinded observers
HCC lesion
<2 cm proven by
surgical resection
in those who had
undergone MRI
a
Gadoxetic acid
alone: 81.4 %
Gadoxetic acid
alone: 98.4 %
Adding DWI analysis to
gadoxetic-acid enhanced
MRI improved the
sensitivity and specifi city
Retrospective (very low)
DWI alone:
78.8 %
DWI alone:
96.8 %
Combined: 92.4 % Combined: 97.5 % Sensitivity of combined
image sets in the
detection of lesions <1
cm is lower than for
those lesions >1 cm
(84.8 % vs. 95.7 %)
Specifi city of combined
image sets in the detection
of lesions <1 cm is
slightly lower than for
those lesions >1 cm
(94.5 % vs. 99.6 %)
Park et al.
[
62 ]
Gadoxetic acid-
enhanced MRI with
or without DWI at
3.0-T as reviewed by
two independent,
blinded observers
Those with
suspected lesion
on MDCT or US
with lesion
<2.0 cm
b
Combined: 98.5 % Combined: 90.9 % Arterial hyperintensity,
hypointensity on HBP
and hyperintensity on
DWI was present in
65 % of <1 cm lesions
Retrospective (very low)
The majority of lesions
that did not have typical
characteristics of HCC on
MDCT were able to be
characterized as HCC
based on HBP and DWI
characteristics
A.P. Desai and H.S. Te
107
Study Imaging method Cohort Sensitivity Specifi city Clinical performance
Study type (Quality of
evidence)
Hwang et al.
[
61 ]
Gadoxetic acid-
enhanced MRI with
or without DWI at
3.0-T as reviewed by
two independent,
blinded observers
OLT recipients
who underwent
MRI within 90
days of OLT
c
Gadoxetic acid
alone: 72 %
Gadoxetic acid
alone: 96 %
Adding DWI analysis to
gadoxetic-acid enhanced
MRI improved the
sensitivity and specifi city
Retrospective (low)
Combined: 79 % Combined: 93 % Sensitivity of gadoxetic
acid-enhanced MRI with
and without DWI
decreased with lesion
size (for combined
imaging, 93 % for
lesions >2.0 cm vs. 61 %
for lesions <1.0 cm)
Sensitivity of gadoxetic
acid-enhanced MRI with
and without DWI
decreased with
increasing severity of
liver disease (for
combined imaging, 97 %
in Child-Pugh class A vs
56 % in Child-Pugh
class C)
a
Control group included those with suspected HCC on initial imaging but with negative diagnostic work up
b
Included individuals without cirrhosis . Individuals excluded if they had not had MDCT as well as MRI. Lesion deemed either HCC or benign hepatocellular
nodule based on imaging criteria, biopsy, surgical resection or explant pathology
c
Included 8/63 non-cirrhotics
9 What Is the Best Way to Screen Cirrhotic Patients for Hepatocellular Carcinoma…
108
Recommendations
1. MRI with HBP and DWI offers the best sensitivity and specifi city of HCC largely
due to its superiority in detecting and characterizing lesions <2 cm. While there
are no data on screening interval for MRI, annual imaging in those with no wor-
risome lesions can be inferred based on tumor doubling time. The cost-
effectiveness of this approach, however, remains to be studied.
2. In the general population, ultrasound with or without serum AFP every 6 months
offers acceptable performance in the screening of HCC and should be used when
cross-sectional imaging is not available or tolerated or is contraindicated. The
combination of US with serum AFP has demonstrated increased accuracy in a
larger prospective study than US alone. Furthermore, the interval change in
serum AFP may offer more value in the detection of HCC than a single serum
AFP assay alone.
3. In those awaiting liver transplant ation , where accurate assessment of the burden
of HCC can signifi cantly alter management , MRI with HPB phase and DWI
should be used, with the best performance noted in those with Child-Pugh class
A and B cirrhosis .
4. Survival benefi t of screening for HCC has yet to be established in randomized
controlled trials, but it is unlikely for such trials to come to fruition due to diffi -
culty with patient enrollment. Limiting screening to those individuals who are
eligible for treatment will improve clinical effectiveness of surveillance
program.
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9 What Is the Best Way to Screen Cirrhotic Patients for Hepatocellular Carcinoma…
113© Springer International Publishing Switzerland 2016
J.M. Millis, J.B. Matthews (eds.), Diffi cult Decisions in Hepatobiliary
and Pancreatic Surgery, Diffi cult Decisions in Surgery: An Evidence-Based
Approach, DOI 10.1007/978-3-319-27365-5_10
Chapter 10
When Is Laparoscopic Liver Resection
Preferred Over Open Resection?
Ana Gleisner and David A. Geller
Abstract Laparoscopic liver resection is being safely performed by surgeons
worldwide for multiple indications. When compared to open liver resection, laparoscopic liver resection is associated with improvements in short-term outcomes such
as decreased blood loss, transfusion rate, perioperative complications, length of
stay, and overall cost. When laparoscopic is performed for malignancies such as
hepatocellular carcinoma and metastatic colorectal cancer, oncological adequacy
needs to be assured in order to avoid detrimental effects in long-term outcomes such
as disease-free survival and overall survival. Current evidence suggests that in wellselected patients, the long-term oncologic outcomes achieved with laparoscopic
liver resection are equivalent to those obtained with open liver resection. To date,
there are no published randomized trials comparing laparoscopic to open liver
resection, although two trials are ongoing.
Keywords Laparoscopic liver resection • Laparoscopic hepatectomy •
Hepatocellular carcinoma • Metastatic colorectal cancer • Liver tumor
Introduction
Laparoscopic liver resection s have been performed for several indications, including both benign lesions and malignancies, with low morbidity and mortality [ 1 , 2 ].
When compared to open resections, laparoscopic liver resection s are associated
with decreased LOS, postoperative pain and complications [ 3 – 6 ]. Yet, when laparo-
scopic liver resections are used for the treatment of malignancies, concerns about
the rates of positive margins and failure to recognize occult metastases have caused
some to question the oncologic adequacy of the procedure [ 7 ]. Because oncologic
A. Gleisner • D. A. Geller (*)
Department of Surgery , University of Pittsburgh ,
3459 Fifth Avenue , Pittsburgh , PA 15213-2582 , USA
e-mail:
gellerda@upmc.edu
114
adequacy infl uences important long-term outcomes , such as recurrence and longterm survival , patient selection for laparoscopic liver resection is premised upon
understanding which surgical indications are most likely to afford the improved
short-term outcomes associated with the laparoscopic technique without compromising the oncologic adequacy of the procedure. This chapter addresses situations
in which laparoscopic surgery is preferred over open liver resection, with discussion
focused on the short-term outcomes of laparoscopic liver resection when compared
to open liver resection for both benign and malignant liver disease as well as longterm outcomes for the most common primary liver malignancy and metastatic disease—hepatocellular carcinoma (HCC) and metastatic colorectal cancer to the liver
(mCRC), respectively.
Search Strategy
A literature search of publications from 2001 to 2014 was performed to identify
published data on laparoscopic liver resection using the PICO outline [ 8 ]
(Table 10.1 ). Databases searched were PubMed, Embase, Science Citation Index
and Cochrane Evidence Based Medicine , restricted for publications in English language. Terms used in the search were “laparoscopic liver resection ,” “ laparoscopic
hepatectomy ,” AND “ open liver resection ,” “open hepatectomy ,” AND (“intraoperative complications” OR “perioperative complications” OR “postoperative complications” OR “ overall survival ” OR “disease-free survival ” OR “long-term” OR
“ outcomes ”). Articles were excluded if they were review articles or non- comparative.
There were no randomized trials. We included 32 cohort studies and 3 meta- analyses
that were classifi ed using the GRADE system [ 9 ].
Table 10.1 PICO table for laparoscopic liver resection
P (Patients) I (Intervention)
C
(Comparator
group) O (Outcomes measured)
Patients with multiple
indications for liver
resection; patients with
indication for liver resection
for hepatocellular carcinoma
and for metastatic colorectal
cancer
Laparoscopic
liver resection
Open liver
resection
Short-term: EBL,
transfusion rate,
postoperative morbidity
and mortality, LOS,
surgical margins, cost
Long-term: overall survival
and disease-free survival
for resection of
malignancies
A. Gleisner and D.A. Geller
115
Results
Short-Term Outcomes of Laparoscopic Liver Resection
Several cohort studies have compared the perioperative outcomes of patients submitted to laparoscopic liver resection with those of patients who underwent open
liver resection . In a study examining the comparative benefi ts of laparoscopic vs.
open hepatectomy , Nguyen et al. analyzed 31 case-cohort matched comparative
studies that compared laparoscopic liver resection in 1,146 patients to open liver
resection in 1,327 patients [ 3 ]. The short-term benefi ts of laparoscopic liver resec-
tion were signifi cantly less blood loss (14 studies), less pRBC transfusions (4 studies), less post-operative pain /narcotic use (8 studies), quicker resumption of diet (8
studies), less overall morbidity (7 studies), and shorter length of stay (24 studies).
For HCC and mCRC, there was no difference in 3- or 5-year overall survival when
compared with well-matched open hepatic resection cases. Thus, the short-term
benefi ts of laparoscopic liver resection were realized without compromising longterm oncologic outcomes.
Several recent meta-analyses have addressed short-term benefi ts of laparoscopic
liver resection compared to open liver resection by analyzing comparative series
[ 4 – 6 ] (Table 10.2 ). These studies have included liver resections for multiple indica-
tions as well as those specifi cally performed for HCC and mCRC. Rao et al. [ 5 ]
included 32 studies published between 1998 and 2009, including excision of malignant lesions, benign lesions or both, as well as one study in which the indication was
live liver donation for transplantation. Most studies described different types of liver
resections and matched the laparoscopic and open resection groups based on characteristics of the patients (i.e. age, gender, presence of cirrhosis and ASA classifi cation), the lesions (i.e. size, location and etiology) and related to the operation (i.e.
type of resection). A total of 2,466 patients were included, 1,161 (47.1 %) in the
laparoscopic group and 1,305 (52.9 %) in the open group. Laparoscopic liver resection was associated with decreased postoperative morbidity (Odds Ratio [OR] 0.62;
95 % Confi dence Interval [CI] 0.20–0.76), decreased length of stay (LOS) (Weighted
mean difference [WMD] −2.96; 95 % CI −3.70 to −2.22 days) and decreased need
for blood transfusion (OR 0.36; 95 % CI 0.23–0.74). The incidence of positive surgical margins for the resection of malignant lesions was also lower in the laparoscopic group (OR 0.30; 95 % CI 0.20–0.76), according to the data in 6 of the 32
studies. Mortality rate was reported in 18 of the 32 studies and was not signifi cantly
different between both groups (p = 0.80).
Yin and colleagues [ 6 ] included 15 studies published between 2001 and 2011,
where laparoscopic liver resection was compared to open resection exclusively for
the treatment of HCC. Lesions were either solitary, restricted to the left lateral lobe
or the peripheral subcapsular right segments of the liver and were treated by limited
resection (three or fewer segments). Among patients treated with laparoscopic
resection, there were signifi cant decreases in EBL (WMD −225, 95 % CI −385 to
−64 ml), need for blood transfusion (OR 0.36; 95 % CI 0.17–0.74), postoperative
10 When Is Laparoscopic Liver Resection Preferred Over Open Resection?