Laparoscopic hepatectomy for hepatocellular carcinoma: A study on the adoption at a large academic center

Abstract

Presenter: Xavier Pereira MD | Montefiore Medical Center Background: Laparoscopic Hepatectomy (LH) for hepatocellular carcinoma (HCC) represents a major change in surgical practice for the established liver surgeon. LH has gradually evolved through the steps of surgical innovation: proof of concept, procedure development, procedure refinement, and now phasing into widespread adoption at most academic centers. However, technical challenges impacting operative outcomes and effects on R0 resection have slowed the adoption of laparoscopy in liver surgery. While landmark studies have confirmed the safety of laparoscopy to early adopters, they often fail to capture the efficacy, safety, and comparable oncologic outcomes that can be seen with the widespread adoption of LH at most academic centers. We sought to describe the adoption of LH for HCC at our institution with an emphasis on early patient selection, a safe and gradual increase in case complexity, and it effects on procedural and oncologic outcomes. Methods: Patients undergoing hepatectomy for HCC between July 2016 to December 2018 were reviewed. Patient demographics, indications for surgery, hepatic disease burden, co-morbidities, intraoperative and postoperative data were reviewed retrospectively. Open (OH) vs. laparoscopic procedures (LH) were matched for comparison od endpoints using Chi square, Student’s T-test, and Mann-Whitney U tests. Results: Comparative distribution of 177 cases on a quarterly timeline is presented (Figure 1), highlighting a steady adoption of LH. Of the 56 patients matched for analysis, 27 underwent open hepatectomy (OH) while 26 underwent LH. These cohorts were well matched without notable difference in the Charlson Comorbidities Index (CCI) (p-value 0.943) or Childs class (p-value 0.077). The LH group showed less tumor burden (p<0.0639) less segments involved (p<0.0063) and less complex resections based on the Iwate difficulty scoring (p<0.0013) indicating an expected bias in patient selection, more conservative for LH. The average LOS, EBL, and intraoperative transfusions were lower in the laparoscopic group vs. the open group (P < 0.0115 and p<0.0483). The proportion of R0/R1 resections was no different between both groups (p<0.2771) achieving R0 resections in 92% of LLRs vs. 80% of OLRs. The median recurrence-free survival and median patient survival was not different between groups. As the study period went on, progression in the learning curve of LH correlated with an increase in the proportion of CCI score >70% and the Iwate difficulty scoring per case, as well as an increase in operative time and a rate of conversions with more challenging cases. Conclusion: Widespread adoption of LH on diseased livers with HCC relies on progressive patient selection reassuring the surgical team on taking more challenging cases. Even with increasingly difficult cases, the complication rate and oncologic outcomes remain comparable to open surgery.