Pure laparoscopic versus open left lateral sectionectomy for hepatocellular carcinoma: A propensity score matching analysis.

Laparoscopic left lateral sectionectomy (LLLS) has been associated with shorter hospital stay and reduced overall morbidity compared with open left lateral sectionectomy (OLLS). Strong evidence has not, however, been provided. In this multicentre double-blind RCT, patients (aged 18-80 years with a BMI of 18-35 kg/m2 and ASA fitness grade of III or below) requiring left lateral sectionectomy (LLS) were assigned randomly to OLLS or LLLS within an enhanced recovery after surgery (ERAS) programme. All randomized patients, ward physicians and nurses were blinded to the procedure undertaken. A parallel prospective registry (open non-randomized (ONR) versus laparoscopic non-randomized (LNR)) was used to monitor patients who were not enrolled for randomization because of doctor or patient preference. The primary endpoint was time to functional recovery. Secondary endpoints were length of hospital stay (LOS), readmission rate, overall morbidity, composite endpoint of liver surgery-specific morbidity, mortality, and reasons for delay in discharge after functional recovery. Between January 2010 and July 2014, patients were recruited at ten centres. Of these, 24 patients were randomized at eight centres, and 67 patients from eight centres were included in the prospective registry. Owing to slow accrual, the trial was stopped on the advice of an independent Data and Safety Monitoring Board in the Netherlands. No significant difference in median (i.q.r.) time to functional recovery was observed between laparoscopic and open surgery in the randomized or non-randomized groups: 3 (3-5) days for OLLS versus 3 (3-3) days for LLLS; and 3 (3-3) days for ONR versus 3 (3-4) days for LNR. There were no significant differences with regard to LOS, morbidity, reoperation, readmission and mortality rates. This RCT comparing open and laparoscopic LLS in an ERAS setting was not able to reach a conclusion on time to functional recovery, because it was stopped prematurely owing to slow accrual. Registration number: NCT00874224 ( https://www.clinicaltrials.gov).

To date, no reported studies comparing anatomical resection (AR) and nonanatomical resection (NAR) for hepatocellular carcinoma (HCC) have restricted cases by tumor location. Thus, right hepatectomy and left lateral sectionectomy are both analyzed together as AR, whereas limited resection of both peripherally and centrally located liver tumors is categorized as NAR. This categorization may result in inaccurate conclusions in the analyses comparing AR and NAR. We conducted a retrospective comparison between AR (n = 30) and NAR (n = 57) for solitary and small (5 cm or less) HCC limited to the left lateral segment (LLS) to clarify whether AR is superior to NAR for HCC in LLS. The 1-, 3-, and 5-year recurrence-free survival rates were 83.3, 71.3, and 52.9 per cent for the AR group and 82.5, 51.0, and 40.7 per cent for the NAR group, respectively (P = 0.10). The 3-, 5-, and 7-year overall survival rates were 96.0, 82.8, and 77.9 per cent for the AR group and 84.1, 77.0, and 54.2 per cent for the NAR group, respectively (P = 0.07). The postoperative complication, recurrence patterns, and secondary treatment types after recurrence were not significantly different between the two groups. The multivariate analysis including the confounders related to background liver function indicated AR to be a significant protective factor against recurrence, although AR did not influence overall survival. AR was superior to NAR in preventing recurrence without increasing postoperative risks among patients with small solitary HCC limited to the LLS, although AR could not improve overall survival.

RCT of open versus laparoscopic left lateral hepatic sectionectomy within an enhanced recovery after surgery programme (ORANGE II study)

“Local recurrence” is not equal to “Local dissemination” after resection for hepatocellular carcinoma

BACKGROUNDThe long-term survival of patients with solitary hepatocellular carcinoma (HCC) following anatomical resection (AR) vs non-anatomical resection (NAR) is still controversial. It is necessary to investigate which approach is better for patients with solitary HCC.AIMTo compare perioperative and long-term survival outcomes of AR and NAR for solitary HCC.METHODSWe performed a comprehensive literature search of PubMed, Medline (Ovid), Embase (Ovid), and Cochrane Library. Participants of any age and sex, who underwent liver resection, were considered following the following criteria: (1) Studies reporting AR vs NAR liver resection; (2) Studies focused on primary HCC with a solitary tumor; (3) Studies reporting the long-term survival outcomes (> 5 years); and (4) Studies including patients without history of preoperative treatment. The main results were overall survival (OS) and disease-free survival (DFS). Perioperative outcomes were also compared.RESULTSA total of 14 studies, published between 2001 and 2020, were included in our meta-analysis, including 9444 patients who were mainly from China, Japan, and Korea. AR was performed on 4260 (44.8%) patients. The synthetic results showed that the 5-year OS [odds ratio (OR): 1.19; P < 0.001] and DFS (OR: 1.26; P < 0.001) were significantly better in the AR group than in the NAR group. AR was associated with longer operating time [mean difference (MD): 47.08; P < 0.001], more blood loss (MD: 169.29; P = 0.001), and wider surgical margin (MD = 1.35; P = 0.04) compared to NAR. There was no obvious difference in blood transfusion ratio (OR: 1.16; P = 0.65) or postoperative complications (OR: 1.24, P = 0.18).CONCLUSIONAR is superior to NAR in terms of long-term outcomes. Thus, AR can be recommended as a reasonable surgical option in patients with solitary HCC.

To evaluate the impact of anatomic and non-anatomic liver resection on prognosis of patients with small hepatocellular carcinoma (HCC) using a meta-analysis. Literature on anatomic versus non-anatomic liver resection for the treatment of small HCC published in public was retrieved. Four non-randomized controlled trials studies were included in this analysis. These studies included a total of 776 patients: 484 treated with anatomic liver resection and 282 treated with non-anatomic resection. No significant differences were found concerning the 1, 3 and 5-year disease-free survival rate between the two groups. There was no significant difference between the two groups when comparing the 1, 3 and 5-year overall survival rate. We use the sensitivity analysis which found anatomic resection could extend the 3-year disease-free survival rate when compared with non-anatomic resection (odds ratio (OR)=0.72, 95% confidence interval (CI): 0.52-0.99, p=0.04). Anatomic liver resection can extend the 3-year disease-free survival rate of patients with small hepatocellular carcinoma. Further randomized controlled trials are needed to define the exact value of anatomic resection and non-anatomic resection for small HCC.

The relative benefit of anatomic resection (AR) versus non-anatomic resection (NAR) of hepatocellular carcinoma (HCC) remains controversial. The objective of this study is to review and compare survival outcomes and recurrence rates of HCC according to tumor size and extent of resection. Data of patients with HCC who underwent curative surgical resection between January 1999 and December 2009 from Asan Medical Center were retrospectively reviewed. To compare survival outcomes between AR and NAR, propensity score matching (PSM) was conducted according to tumor size. A total of 986 patients were analyzed; 812 patients received AR and 174 patients underwent NAR. The 5-year OS rate of HCC less than 5 cm was 78.1% and 62.4% in AR and NAR, respectively (p = 0.002). The 5-year RFS rate of HCC less than 5 cm was 48.2% and 36.8% in AR and NAR, respectively (p = 0.017). The 5-year OS rate of HCC greater than or equal to 5 cm was 48.6% and 47.1% in AR and NAR, respectively (p = 0.629). The 5-year RFS rate of HCC greater than or equal to 5 cm was 30.4% and 27.5% in AR and NAR, respectively (p = 0.462). After PSM, the OS and RFS rate of HCC less than 5 cm were significantly better in the AR group. However, in HCC greater than or equal to 5 cm, there were no significant difference between the AR and the NAR group. AR in HCC less than 5 cm decreased the risk of tumor recurrence and improved OS. In HCC with diameter over 5 cm, AR and NAR showed comparable survival outcomes.

Background and Objectives: The survival benefit of anatomical liver resection for hepatocellular carcinoma has not been elucidated yet. In this study, we aimed to investigate the effects of anatomic and non-anatomic liver resection on surgical outcomes in patients with hepatocellular carcinoma. Materials and Methods: A retrospective analysis of patients undergoing anatomic or non-anatomic resections due to hepatocellular carcinoma between March 2006 and October 2019 was conducted. Demographics, preoperative laboratory assessments, treatment strategies, and postoperative outcomes were analyzed. Results: The total cohort consisted of 94 patients, with a mean age of 63.1 ± 8.9 years, and 74.5% were male. A total of 41 patients underwent anatomic liver resection, and 53 patients underwent non-anatomic resection. The overall survival rates were found to be similar (5-year overall survival was 49.3% for anatomic resection and 44.5% for non-anatomic resection). Estimated median overall survival times were 58.5 months and 57.3 months, respectively (p = 0.777). Recurrence-free 1-, 3-, and 5-year survival rates were found to be 73.6%, 39.1%, and 32.8% in the non-anatomic resection group and 48.8%, 22.7%, and 22.7% in the anatomic resection group, respectively. Grade three or higher complication rates were found to be similar among the groups. Conclusions: This study did not find a difference between two surgical methods, in terms of survival. A tailored selection of the resection method should be made, with the aim of complete removal of tumoral lesions and leaving a suitable functional liver reserve, according to the parenchymal quality and volume of the liver remnant.

Background The role of anatomical resection (AR) in hepatocellular carcinoma (HCC) remains controversial, particularly for tumors ≤ 5 cm without vascular invasion. We aimed to evaluate the long‐term outcomes of AR versus non‐anatomical resection (NAR) in solitary HCC presumed negative for microvascular invasion (MVI) and intrahepatic metastasis (IM). Methods We retrospectively analyzed 303 patients with solitary HCC who underwent hepatectomy between 2002 and 2019. Predictive factors for MVI and IM were identified, and 214 patients with solitary HCC ≤ 5 cm and predicted absence of MVI and IM were further analyzed. We compared the perioperative and oncological outcomes between the AR ( n = 94) and NAR ( n = 120) groups. Subsequently, we conducted propensity score matching ( n = 41 per group) and performed subgroup analyses based on tumor size. Results Des‐γ‐carboxy prothrombin &gt; 150 mAU/mL was identified as an independent predictor for MVI and IM. Compared with the NAR group, the AR group had a significantly longer operative time, greater blood loss, and higher rate of complications, but showed no significant differences in recurrence‐free survival and overall survival. Recurrence‐free survival and overall survival remained comparable between the two groups after propensity score matching. Subgroup analyses by tumor size (0–2.0 and 2.1–5.0 cm) showed no prognostic advantage for AR over NAR. Conclusions For solitary HCC ≤ 5 cm without predicted MVI and IM, NAR and AR result in comparable long‐term outcomes. The resection strategy should prioritize remnant liver function over anatomical extent.

Laparoscopic vs. open left lateral sectionectomy: an update systematic review and meta-analysis of randomized and non-randomized controlled trials

Left lateral sectionectomy for donor hepatectomy is a well-established alternative to deceased donor pediatric liver transplantation. However, very little is available on the laparoscopic approach (laparoscopic left lateral sectionectomy [L-LLS]). With the aim to assess safety, reproducibility under proctorship, and outcomes following living donor liver transplantation in children, a comparative single-center series using propensity score matching (PSM) to evaluate open left lateral sectionectomy (O-LLS) versus L-LLS was carried out in a relatively short time period in a high-volume pediatric transplant center. A retrospective, observational, single-center, PSM study was conducted on 220 consecutive living donor hepatectomies from January 2011 to April 2017. The variables considered for PSM were as follows: year of operation, recipient age, indication for transplant, recipient weight, donor sex, donor age, and donor body mass index. After matching, 72 O-LLSs were fit to be compared with 72 L-LLSs. Operative time and warm ischemia time were significantly longer in L-LLSs, whereas blood loss and overall donor complication rates were significantly lower. Postoperative day 1 and 4 pain scores were significantly less in the L-LLS group (P = 0.015 and 0.003, respectively). The length of hospital stay was significantly shorter in L-LLS (4.6 versus 4.1 days; P = 0.014). Overall donor biliary complications were 9 (12.5%) and 1 (1.4%) for O-LLS and L-LLS (P = 0.022), respectively. Vascular complications occurred in 3 (4.2%) children without graft loss in the laparoscopic group. The 1-, 3-, and 5-year overall patient survival rates were 98.5%, 90.9%, and 90.9% in the O-LLS group and in the L-LLS group 94.3%, 92.7%, and 86.8% (P = 0.28). In conclusion, L-LLS for donor hepatectomy is a safe and reproducible technique yielding better donor perioperative outcomes with respect to the conventional approach with similar recipient outcomes.

New frontiers in liver resection for hepatocellular carcinoma.

The oncologic advantage of anatomic resection (AR) for primary hepatocellular carcinoma (HCC) remains controversial. This study aimed to evaluate the clinical advantages of AR for primary HCC by using propensity score-matching and by assessing treatment strategies for recurrence after surgery. The study reviewed data of patients who underwent AR or non-anatomic resection (NAR) for solitary HCC (≤5cm) in two institutions between 2004 and 2017. Surgical outcomes were compared between the two groups in a propensity score-adjusted cohort. The time-to-interventional failure (TIF), defined as the elapsed time from resection to unresectable/unablatable recurrence, also was evaluated. The inclusion criteria were met by 250 patients: 77 patients (31%) with AR and 173 patients (69%) with NAR. In the propensity score-matched populations (AR, 67; NAR, 67), the 5-year recurrence-free survival (RFS) for AR was better than for NAR (62% vs 35%; P=0.005). No differences, however, were found in the 5-year overall survival between the two groups (72% vs 78%; P=0.666). The 5-year TIF rates for the NAR group (60%) also were similar to those for the AR group (66%) (P=0.413). In the cohort of 67 patients, curative repeat resection or ablation therapy was performed more frequently for the NAR patients (42%) than for the AR patients (10%) (P<0.001). For solitary HCC, AR decreases recurrence after the initial hepatectomy. However, aggressive curative-intent interventions for recurrence compensate for the impaired RFS, even for patients undergoing NAR.

This study aimed to evaluate the effect of anatomic resection on long-term outcomes in patients with pathologic T1-T2 (pT1-T2) hepatocellular carcinoma. A retrospective analysis of 158 consecutive patients who underwent either anatomic (n = 95) or nonanatomic (n = 63) resection for pT1-T2 hepatocellular carcinoma was conducted. Anatomic resection was defined as the complete removal of at least one Couinaud segment containing the tumor; nonanatomic resection was defined as removal of the tumor plus a rim of nonneoplastic liver parenchyma. The median follow-up time was 83 months. Patients who underwent anatomic resection were characterized by lower prevalence of cirrhosis (P = .015), more favorable hepatic function (P = .001), larger tumor size (P = .029), and higher prevalence of vascular invasion (P = .008) compared with patients who underwent nonanatomic resection. Anatomic resection provided better survival (median survival time, 122 months) than nonanatomic resection (median survival time, 76 months; P = .0358). Patients who underwent anatomic resection had better disease-free survival (P = .0121). Anatomic resection independently improved both survival (hazard ratio, .46; P = .003) and disease-free survival (hazard ratio, .55; P = .008). When stratified for pT classification, the effectiveness of anatomic resection remained only in patients with pT2 tumors in terms of survival (P = .0012) and disease-free survival (P = .0004). Anatomic resection independently improves long-term survival in patients with T1-T2 hepatocellular carcinoma, probably because of the clearance of venous tumor thrombi within the resected domain.

The aim of this study was to examine the impact of anatomical resection (AR) versus non-anatomical resection (NAR) on the survival outcomes in patients with intrahepatic cholangiocarcinoma (ICC). Data on 702 consecutive patients who underwent either AR (n = 319) or NAR (n = 383) for ICC were reviewed. Disease-free survival (DFS) and overall survival (OS) following AR versus NAR was compared using propensity score matching (PSM). Subgroups of patients who benefited from AR versus NAR were examined after being stratified by the 8th TNM staging of ICC. AR and NAR had similar complication rates (26.6% vs. 25.1%, p = 0.634). AR was associated with better 1-, 3-, and 5-year DFS and OS rates compared with NAR after PSM (58.1%, 35.7% and 28.1% vs. 44.1%, 23.9% and 18.0%; 72.9%, 45.7% and 36.0% vs. 62.0%, 30.8% and 25.3%; both p = 0.002). On multivariate analysis, NAR was associated with worse DFS and OS than AR [hazard ratio (HR) 1.461 and 1.488; 95% confidence interval (CI) 1.184-1.804 and 1.189-1.863, respectively]. Stratified analysis demonstrated similar outcomes following AR versus NAR for ICC at stages IA, II with vascular invasion, and III with visceral peritoneum perforation, local extrahepatic invasion and nodal metastasis, while NAR was associated with worse DFS and OS versus AR for stages IB (HR 1.897 and 2.321; 95% CI 1.179-3.052 and 1.376-3.914, respectively) or II ICC without vascular invasion (2.071 and 2.077; 95% CI 1.239-3.462 and 1.205-3.579, respectively). AR was associated with better survival outcomes compared with NAR in ICC patients with stage IB or II tumors without vascular invasion.