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116
Table 10.2 Short-term outcomes for patients submitted to laparoscopic liver resection
Author
Number of
patients
Indication
Number of
studies
(publication
year)
pOR for
postoperative
morbidity
(95 % CI)
EBL
(95 %
CI)
LOS
(95 %
CI)
pOR for
Blood
Transfusion
Study type ( quality
of evidence) LLR/OLR
Rao (2012)
[
5 ]
1161/1305 Benign/malignant 32
(1998–2009)
0.35
(0.28–0.45)
−184
a
ml −2.96
(–3.70 to
−2.22)
a
days
0.36
(0.23–0.74)
Metaanalysis
(moderate)
Yin (2013)
[
6 ]
485/753 HCC 15
(2001–2011)
0.37
(0.27–0.52)
−225
(−385 to
−64)
a
ml
−4.81
(−6.66 to
−2.96)
a
days
0.36
(0.17–0.74)
Metaanalysis
(moderate)
Schiffman
(2014) [
4 ]
242/368 mCRC 8
(2009–2013)
0.70
(0.52–0.96)
−0.70 (0
to
−1.41)
b
−1.50
(−2.60 to
−0.41)
b
0.51
(0.32–0.81)
Metaanalysis
(moderate)
LLR laparoscopic liver resection , OLR open liver resection , HCC hepatocellular carcinoma, mCRC metastatic colorectal cancer , pOR pooled odds ratio, CI
confi dence interval, EBL estimated blood loss, LOS length of stay
a
Weighted mean difference
b
Standard mean difference
A. Gleisner and D.A. Geller
117
complications (OR 0.37; 95 % CI 0.27–0.52) and LOS (WMD −4.81; 95 % CI
−6.66 to −2.96 days). There was no signifi cant difference in the rate of negative
margins (OR 1.63; 95 % CI 0.82–3.22).
The most recent meta-analysis, by Schiffman and colleagues [ 4 ], summarized
data published between 2009 and 2013 that compared laparoscopic surgery to open
resection for the treatment of hepatic mCRC. Only matched cohorts were included,
resulting in 8 studies with 242 patients submitted to laparoscopic surgery and 368
patients submitted to open resection. The fi ndings also showed improvement in
perioperative outcomes for patients who underwent laparoscopic surgery, including
reduced EBL (standard mean difference [SMD] – 0.70; 95 % CI 0 to −1.41), need
for blood transfusion (OR 0.51; 95 % CI 0.32–0.81), postoperative morbidity (OR
0.70; 95 % CI 0.52–0.96) and LOS (SMD −1.50; 95 % CI −2.60 to −0.41).
Although there is some redundancy in the articles included in the three metaanalyses, the effect of laparoscopic surgery in the perioperative outcomes is consistent and with large magnitude. It is possible, however, that important confounders
have not been accounted for in these observational studies. For example, more
accessible lesions may have been chosen for the laparoscopic approach, which
could result in overestimation of its effect. Additionally, the determination of how
accessible a tumor is can be hard to measure and varies considerably among surgeons. Further, inherent selection bias exists even in well-matched case cohort
series.
In addition to the favorable perioperative outcomes associated with laparoscopic
liver resection , there is evidence suggesting laparoscopic liver resection s may be
more cost-effective as well. In a retrospective cohort study, Vanounou and colleagues [ 10 ] found that laparoscopic left lateral sectionectomy was $1,527–2,939
more cost effective per patient compared to open left lateral sectionectomy. Bhojani
and colleagues [ 11 ] reported results from 57 patients who underwent attempted
laparoscopic resection matched to 2 open cases for multiple parameters including
the number of segments removed. Eight (14 %) cases were converted to open and
most perioperative outcomes were similar between the two groups. The median cost
for laparoscopic surgery was lower when compared to open resections ($11,376 vs
$12,523), but the difference did not achieve statistical signifi cance (p = 0.077).
Another retrospective cohort by Cannon and colleagues [ 12 ] found an overall
decrease in cost of liver resections performed laparoscopically (weighted average
mean cost [WAMC] of $58,401 versus $69,728 for open resections). However,
when only right hepatectomies were considered, the laparoscopic approach actually
resulted in increased cost (WAMC $69,544 versus $68,266 for open resection),
despite the fact that the patients in the laparoscopic group were more likely to have
an “on course” hospitalization—suggesting that the cost effectiveness of laparoscopic surgery may vary according to the complexity of the procedure.
10 When Is Laparoscopic Liver Resection Preferred Over Open Resection?
118
Long-Term Outcomes in Laparoscopic Liver Resection
Evaluation of the oncological adequacy of the laparoscopic approach to liver resection is crucial when this technique is applied to the treatment of malignancies.
Concerns are mainly related to the rate of negative margins achieved and the ability
to recognize occult metastasis, which would result in decreases in the disease-free
and overall survival .
Hepatocellular Carcinoma
Several studies have reported long-term results on cohorts of patients who underwent laparoscopic resection of HCC. These studies included retrospective or prospective cohorts of patients submitted to laparoscopic surgery compared to
retrospective cohorts of patients submitted to open resection (Table 10.3 ). With the
exception of one study, which reported a signifi cantly higher 3-year survival rate for
those submitted to laparoscopic resection (89 % versus 55 % in the open resection
group) [ 13 ], no signifi cant differences in disease-free or overall survival were
observed. The largest study, by Ker and colleagues, [ 14 ] included 116 patients sub-
mitted to laparoscopic resection and 208 patients submitted to open resection.
Overall survival was comparable between both groups (3- and 5-year overall survival 70 % and 62 % for laparoscopic and 76 % and 72 % for open resection). The
meta-analysis by Yin and colleagues [ 6 ] included 12 studies that reported long-term
outcomes of patients operated for HCC. The pooled hazard ratio (HR) for 3- and
5-year overall survival for laparoscopic surgery was 0.98 (95 % CI 0.72–1.33) and
0.99 (95 % CI 0.74–1.33), respectively. Similarly, the pooled HR for 3- and 5-year
recurrence free survival was not signifi cantly different for those submitted to laparoscopic surgery when compared to open (HR 1.04; 95 % CI 0.81–1.34 and HR
1.01; 95 % CI 0.75–1.35, respectively). More importantly, no signifi cant heterogeneity was found between the studies.
Metastatic Colorectal Cancer
Long-term results for patients submitted to laparoscopic and open liver resection for
metastatic colorectal cancer are summarized in Table
10.4 . Of the 11 cohort studies
identifi ed in the literature review, all but one matched with regard to clinical, tumor
and/or procedure-related characteristics, and there were no difference in diseasefree or overall survival between patients in the laparoscopic and open liver resection
cohorts. The studies included a minimum of 13 and a maximum of 60 patients in the
laparoscopic group. Disease-free survival was reported in seven studies, ranging
between 14 % and 63 % in 3-years and 14 % and 42 % in 5-years for those who
underwent laparoscopic resection, and between 18 % and 46 % in 3-years and 18 %
and 38 % in 5-years for patients who underwent open resection.
A. Gleisner and D.A. Geller
119
Table 10.3 Long-term outcomes for patients submitted to laparoscopic liver resection for hepatocellular carcinoma
Author
Number of
patients
Median
follow-up
(months)
Median
DFS
(months)
Median OS
(months)
3-years
DFS (%)
5-years
DFS (%)
3-years OS
(%)
5-years OS
(%)
Study type ( quality
of evidence) LLR/OLR LLR/OLR LLR/OLR LLR/OLR LLR/OLR LLR/OLR LLR/OLR LLR/OLR
Kim (2014)
[
15 ]
29/29 48/60 NR NR 62/61 54/40 100/92 92/88 Retrospective
matched-cohort
(low)
Cheung
(2013) [
16 ]
32/64 NR 79/29 92/71 73/50 55/44 88/73 77/57 Retrospective
matched-cohort
(low)
Kobayashi
(2013) [
17 ]
56/27 19/68 NR NR 50/62 NR 100/100 NR Retrospective
matched-cohort
(low)
Ker (2011)
[
14 ]
116/208 94/94 NR NR NR NR 70/76 62/72 Retrospective
cohort (low)
Truant (2011)
[
18 ]
35/53 36/36 NR NR NR 36/34 NR 70/46 Retrospective
matched-cohort
(low)
Lee (2011)
[
19 ]
33/50 35/29 NR NR 51/56 45/56 82/81 76/76 Retrospective
matched-cohort
(low)
Hu (2011)
[
20 ]
30/30 NR NR NR NR NR 76/77 50/53 Retrospective
cohort (low)
Kim (2011)
[
21 ]
26/29 22/25 NR NR NR 57/56 NR NR Retrospective
matched-cohort
(low)
(continued)
10 When Is Laparoscopic Liver Resection Preferred Over Open Resection?
120
Table 10.3 (continued)
Author
Number of
patients
Median
follow-up
(months)
Median
DFS
(months)
Median OS
(months)
3-years
DFS (%)
5-years
DFS (%)
3-years OS
(%)
5-years OS
(%)
Study type ( quality
of evidence) LLR/OLR LLR/OLR LLR/OLR LLR/OLR LLR/OLR LLR/OLR LLR/OLR LLR/OLR
Tranchart
(2010) [
22 ]
42/42 30/35 NR NR 61/54 46/37 74/73 60/47 Retrospective
matched-cohort
(low)
Aldrighetti
(2010) [
23 ]
16/16 32/32 23/31 40/48 NR NR NR NR Retrospective
matched-cohort
(low)
Belli (2009)
[
24 ]
54/125 24/24 38 /– 63 /– 52/55 NR 67/63 NR Retrospective
matched-cohort
(low)
Sarpel (2009)
[
25 ]
20/56 24/18 NR NR NR NR NR 95/75 Retrospective
matched-cohort
(low)
Endo (2009)
[
26 ]
10/11 NR NR NR NR 24/19 NR 57/48 Retrospective
matched-cohort
(low)
Lai (2009)
[
27 ]
25/33 29/29 NR NR 52/56 NR 60/60 NR Retrospective
matched-cohort
(low)
Cai (2008)
[
28 ]
31/31 NR NR 70/61 NR NR 67/74 56/54 Retrospective
matched-cohort
(low)
Kaneko
(2005) [
29 ]
30/28 NR NR NR 45/50 31/29 80/77 61/62 Retrospective and
prospective
matched-cohort
(low)
A. Gleisner and D.A. Geller
121
Author
Number of
patients
Median
follow-up
(months)
Median
DFS
(months)
Median OS
(months)
3-years
DFS (%)
5-years
DFS (%)
3-years OS
(%)
5-years OS
(%)
Study type ( quality
of evidence) LLR/OLR LLR/OLR LLR/OLR LLR/OLR LLR/OLR LLR/OLR LLR/OLR LLR/OLR
Laurent
(2003) [
13 ]
13/13 NR NR NR 56/54 NR 89/55* NR Retrospective and
prospective
matched-cohort
(low)
Shimada
(2001) [
30 ]
17/38 17/29 NR NR NR 72/72 NR 48/38 Retrospective and
prospective
matched-cohort
(low)
DFS : Disease-free survival , OS Overall survival, LLR laparoscopic liver resection , OLR open liver resection , NR not reported
10 When Is Laparoscopic Liver Resection Preferred Over Open Resection?
122
Table 10.4 Long-term outcomes for patients submitted to laparoscopic liver resection for metastatic colorectal cancer
Author
Number of
patients
Median
follow-up
(mos)
Median
DFS (mos)
Median OS
(mos)
3-years DFS
(%)
5-years DFS
(%)
3-years OS
(%)
5-years OS
(%)
Study type ( quality
of evidence) LLR/OLR LLR/OLR LLR/OLR LLR/OLR LLR/OLR LLR/OLR LLR/OLR LLR/OLR
Montalti
(2014) [
31 ]
57/57
41/54 NR NR 39/42 29/38 75/75
60/65
Retrospective
matched-cohort
(low)
Iwahashi
(2014) [
32 ]
21/21 NR NR NR 14/33 14/25 84/89 42/51 Retrospective
matched-cohort
(low)
Guerron
(2013) [
33 ]
40 /40 16/16 23/ 23 NR NR NR 89/81
(2-years)
NR Retrospective
matched-cohort
(low)
Qiu (2013)
[
34 ]
30/30 NR NR NR NR NR NR NR Retrospective
matched-cohort
(low)
Cannon
(2012) [
35 ]
35/140 NR NR NR 37/39 15/22 63/60 36/42 Retrospective
matched-cohort
(low)
Cheung
(2013) [
36 ]
20/40 NR 9.8/10.9 69/42 42/18 42/18 54/65 54/22 Retrospective
matched-cohort
(low)
Topal
(2012) [
37 ]
20/20 NR NR NR NR 43/23 NR 48/46 Retrospective
matched-cohort
(low)
Hu (2012)
[
38 ]
13/13 NR NR NR NR NR 55/54 27/31 Retrospective
matched-cohort
(low)
A. Gleisner and D.A. Geller
123
Nguyen
(2011) [
3 ]
24/25 27/29 NR NR 63/46 NR 75/79 NR Retrospective
matched-cohort
(low)
Abu Hilal
(2010) [
39 ]
50/85 22/22 NR NR NR NR NR NR Retrospective cohort
(low)
Castaing
(2009) [
40 ]
60/60 30/33 47/40 NR 47/40 35/27 82/70 64/56 Retrospective
matched-cohort
(low)
DFS Disease-free survival , OS Overall survival, LLR laparoscopic liver resection , OLR open liver resection , NR not reported
10 When Is Laparoscopic Liver Resection Preferred Over Open Resection?
124
In the meta-analysis by Schiffman and colleagues [ 4 ], which included eight
matched cohort studies comparing laparoscopic versus open resection of colorectal
liver metastasis, long-term outcomes were reported in all studies. Again, there were
no differences in disease-free and overall survival between laparoscopic and open
resection cohorts. The 3- and 5-year mean disease-free survival was 47.1 % and
31.9 % in the laparoscopic group and 40.4 % and 25.5 % in the open resection
group. The 3- and 5-year mean overall survival rate was 72.7 % and 51.4 % in the
laparoscopic group and 67.2 % and 45.9 % in the open resection group. Importantly,
the mean number of metastasis was 1.4 for the laparoscopic group and 1.5 for the
open resection group (p = 0.14), implying that the data on long-term results of laparoscopic resection for mCRC cancer is only applicable to patients with limited disease (one or two tumors).
Of note, there have been no reports of peritoneal tumor seeding with laparoscopic liver resection of neither HCC nor mCRC.
The major limitation of the data on long-term outcomes comparing laparoscopic
and open liver resection s is the lack of randomized trials. Despite the fact that most
cohorts were matched with regard to signifi cant clinical, tumor and procedurerelated factors, residual confounding and selection bias is certainly a possibility in
these observational studies.
Recommendations
Laparoscopic liver resection is associated with decreased EBL, need for transfusion, perioperative morbidity , and LOS when compared to open liver resection .
Although this data is entirely based on observational studies, the magnitude of the
effects is high and there is consistency across several studies (evidence quality moderate). The rate of negative margins is at least equivalent between the two techniques (evidence quality low). Laparoscopic surgery seems to be cost-effective,
especially for minor liver resections (evidence quality very low).
Long-term term outcomes , disease-free survival and overall survival , are equivalent in patients with either HCC or limited (one or ;two lesions) metastatic colorectal cancer submitted to laparoscopic liver resection when compared to open liver
resection . Yet, the lack of randomized trials raises concerns regarding selection bias
and residual confounding variables. It is plausible that surgeons selected patients
with tumors with more favorable characteristics, such as tumor location, for laparoscopic procedures, which would overestimate the treatment effect of the laparoscopic procedure (evidence quality low).
We therefore make a weak recommendation for laparoscopic liver resection in
patients with liver lesions, including hepatocellular carcinoma and limited metastatic colorectal cancer , for the potential benefi ts in perioperative outcomes and possibly cost, with no evidence showing compromise in long-term outcomes for
patients with malignancy.
A. Gleisner and D.A. Geller
125
A Personal View of the Data
Laparoscopic liver resection s have been performed safely in over 8,000 patients
worldwide. Patient selection according to the surgeon’s expertise is key to assure
the short-term benefi ts of laparoscopic surgery . The current evidence also suggests
long-term outcomes for laparoscopic liver resection are equivalent to those for open
liver resections in well-selected patients, when the procedure can be performed
without compromising the oncological adequacy. A more precise estimation of the
treatment effect of laparoscopic liver resection in short- and long-term outcomes
can only be determined by randomized trials, which may be diffi cult to perform
when patients have a choice between laparoscopic and open resections.
Recommendations
• Laparoscopic liver resection should be considered for patients with benign liver
lesions, as it is associated with decreased morbidity and LOS (evidence quality
moderate; strong recommendation).
• Laparoscopic liver resection can be considered for patients with malignancies
such as HCC or limited metastatic colorectal lesions (one or two tumors), as it is
associated with improved short-term outcomes without detriment to long-term
outcomes (evidence quality low; weak recommendation).
References
1. Nguyen KT, Gamblin TC, Geller DA. World review of laparoscopic liver resection-2,804
patients. Ann Surg. 2009;250(5):831–41.
2. Reddy SK, Tsung A, Geller DA. Laparoscopic liver resection. World J Surg.
2011;35(7):1478–86.
3. Nguyen KT, Marsh JW, Tsung A, Steel JJ, Gamblin TC, Geller DA. Comparative benefi ts of
laparoscopic vs open hepatic resection: a critical appraisal. Arch Surg. 2011;146(3):348–56.
4. Schiffman SC, Kim KH, Tsung A, Marsh JW, Geller DA. Laparoscopic versus open liver
resection for metastatic colorectal cancer: a metaanalysis of 610 patients. Surgery.
2015;157(2):211–22.
5. Rao A, Rao G, Ahmed I. Laparoscopic or open liver resection? Let systematic review decide
it. Am J Surg. 2012;204(2):222–31.
6. Yin Z, Fan X, Ye H, Yin D, Wang J. Short- and long-term outcomes after laparoscopic and open
hepatectomy for hepatocellular carcinoma: a global systematic review and meta-analysis. Ann
Surg Oncol. 2013;20(4):1203–15.
7. Buell JF, Cherqui D, Geller DA, et al. The international position on laparoscopic liver surgery:
the Louisville Statement, 2008. Ann Surg. 2009;250(5):825–30.
8. Haroon M, Phillips R. “There is nothing like looking, if you want to fi nd something” – asking
questions and searching for answers – the evidence based approach. Arch Dis Child Educ Pract
Ed. 2010;95(2):34–9.
10 When Is Laparoscopic Liver Resection Preferred Over Open Resection?