Laparoscopic Right Hepatectomy for Hepatocellular Carcinoma Following Sequential TACE–PVE: A Multicentric Analysis of Textbook Outcome

Abstract

Purpose: Major hepatectomy for hepatocellular carcinoma (HCC) is often preceded by sequential transcatheter arterial chemoembolization (TACE) and portal vein embolization (PVE). Laparoscopic approach offers better short-term outcome, especially through a higher rate of Textbook Outcome (TO) achievement. Thus, the ideal strategy would be to propose a laparoscopic approach after TACE/PVE for HCC. However, laparoscopic major hepatectomy in the context of underlying liver disease remains a challenging procedure. The aim of the present study was to assess short-term outcome and long-term outcome in a multicentric series of patients who underwent laparoscopic or open right hepatectomy following TACE/PVE for HCC. Method: All patients with HCC who underwent major hepatectomy after TACE/PVE were retrospectively included. Quality of surgical care was defined by TO combining 6 criteria. Short and long-term outcome were compared between the (LLR) group and the open liver resection (OLR) group before and after propensity score matching (PSM). Results: Between 2005 and 2019, 117 patients were included, 41 patients in LLR group and 76 patients in OLR group. OLR patients had larger tumors (median 65 mm vs 37 mm, p<0.001). Overall morbidity was comparable between LLR and OLR groups (52 vs 46%, p=0.79) as well as severe complications (11 vs 14%, p=1.00) ). Tumor-free margin was obtained in 96% of patients in LLR and 86% in OLR group (p=0.06). After PSM, patients’ and tumoral characteristics were comparable between LLR (n=27) and OLR (n=28) patients, as well as postoperative morbidity (overall morbidity 52% in matched LLR vs 46% in matched OLR, p=0.79). Five-year overall (OS) and disease-free survival (DFS) weren’t different between the 2 groups (55% in matched LLR vs 77% in matched OLR, p= 0.35; and 13% in matched LLR vs 17% in matched OLR, p=0.97, respectively). In LLR group, TO was completed in 66% of patients vs 37% in OLR group (p=0.02). Laparoscopic resection was the only predictive factor for TO achievement (HR 4.27, [1.77-10.28], p=0.001). Completion of TO was independently associated with a better 5-year OS (65.2% vs 42.5%, p=0.007) but not with 5-year DFS (26.9% vs 13.0%, p=0.17). Conclusion: Major LLR after TACE/PVE should be considered as an effective option with increasing chance of TO achievement and also, a better 5-year OS.