Open Liver Resection Research Articles

Laparoscopic access is the modern standard for extended liver resection

Objective. To evaluate the safety and early results of laparoscopic extended liver resection in case of focal liver pathology by retrospective comparison with the relevant parameters of a similar open intervention. Materials and methods. The study involved 162 patients who were divided into two groups: Group 1 – 50 patients who underwent laparoscopic extended liver resection, and Group 2 – 112 patients who underwent open extended liver resection. The groups were compared by age structure, sex, body mass index, type of pathology (benign/malignant), as well as by characteristics of surgical intervention and postoperative period. Statistical analysis included a t–test for independent samples, Pearson's chi–square test, and other appropriate methods with the calculation of the confidence level p (parametric criterion). The difference in indicators was considered statistically significant at p < 0.05. Results. Laparoscopic osshire for liver resection was longer (p = 0.0012), but was associated with a lower level of pain according to the visual analog scale (p = 0.02) and fewer bed days to discharge (p = 0.0007) than a similar open intervention. There was no statistically significant difference between the groups in terms of age structure, body mass index, number of liver tumors, blood loss, complication rate, and degree of ischemic liver damage. Conclusions. Laparoscopic extended liver resection is a less invasive method than open liver resection, and patients recover faster after it, although its duration is longer. At the same time, laparoscopic and open intervention had a similar incidence of complications, which indicates acceptable safety and high clinical efficacy of the laparoscopic approach in the treatment of patients with liver disease.

Gradual expansion of the indications for minimally invasive liver resection to include highly complex procedures may improve postoperative outcomes

Aim: Liver resection is performed in patients with benign and malignant liver tumors. Advancements in surgical instruments and improved perioperative management have enabled safe laparoscopic and robotic liver resections. Herein, we aimed to evaluate the patients who underwent minimally invasive liver resection (MISLR) and compare their short-term outcomes with those of patients who underwent open liver resection (OLR), according to surgical complexity. Methods: Data of patients who underwent liver resection at our institution from January 2011 to August 2023 were obtained from a prospectively maintained database. We gradually expanded the indications for MISLR from technically less demanding procedures to intermediate- and high-complexity MISLRs. The procedures were categorized into three grades (low, intermediate, and high) according to the liver resection complexity classification. Results: Of the 1,866 patients who underwent liver resection, 953 were included in the analysis. Of the 953 patients, 781 underwent OLR and 172 underwent MISLR. The operative time and estimated blood loss increased with the increase in surgical complexity in the MISLR group, which was similar to finding in the OLR group. The complication rate also increased with the increase in surgical complexity in the OLR group (low complexity vs. high complexity, 34.8% vs. 50.1%). However, the complication rate was steadily low and approximately 10% across all complexity grades in the MISLR group. Conclusion: Careful selection and gradual expansion of the indications of MISLR may facilitate improved postoperative outcomes in patients undergoing highly complex MISLRs.

Initial Experience With Robotic Liver Resection in the United States.

This study's aim was to show the feasibility and safety of robotic liver resection (RLR) even without extensive experience in major laparoscopic liver resection (LLR). A single center, retrospective analysis was performed for consecutive liver resections for solid liver tumors from 2014 to 2022. The analysis included 226 liver resections, comprising 127 (56.2%) open surgeries, 28 (12.4%) LLR, and 71 (31.4%) RLR. The rate of RLR increased and that of LLR decreased over time. In a comparison between propensity score matching-selected open liver resection and RLR (41:41), RLR had significantly less blood loss (384 ± 413 vs 649 ± 646mL, P = .030) and shorter hospital stay (4.4 ± 3.0 vs 6.4 ± 3.7 days, P = .010), as well as comparable operative time (289 ± 123 vs 290 ± 132 mins, P = .954). A comparison between LLR and RLR showed comparable perioperative outcomes, even with more surgeries with higher difficulty score included in RLR (5.2 ± 2.7 vs 4.3 ± 2.5, P = .147). The analysis of the learning curve in RLR demonstrated that blood loss, conversion rate, and complication rate consistently improved over time, with the case number required to achieve the learning curve appearing to be 60 cases. The findings suggest that RLR is a feasible, safe, and acceptable platform for liver resection, and that the safe implementation and dissemination of RLR can be achieved without solid experience of LLR.

Benefits of laparoscopic liver resection for liver tumors in obese patients: a meta-analysis.

The superiority of laparoscopic liver resection (LLR) and open liver resection (OLR) in obese patients remains controversial. The study aims to assess the available literature and compare the perioperative outcomes of LLR and OLR for liver tumors in obese patients. We searched PubMed, Cochrane Library, Embase, and Web of Science databases for studies comparing LLR and OLR. Odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated. Nine studies were included, with a total of 1116 patients (LLR group: 482 patients; OLR group: 634 patients). Compared with OLR, LLR has lower overall morbidity (OR 0.47, 95% CI 0.34, 0.64), major complications (OR 0.45, 95% CI 0.25, 0.82), surgical site infection (OR 0.18, 95% CI 0.07, 0.48), bile leak (OR 0.45, 95% CI 0.22, 0.95), less blood loss (MD, -329.12 mL; 95% CI, -623.35, -34.88), and shorter length of stay (MD, -5.20 days; 95% CI, -7.43, -2.97). There were no significant differences in mortality, operation time, liver failure, and blood transfusion between the two groups. LLR for obese patients is safe and feasible. Compared to OLR, it offers better short-term outcomes. Further randomized controlled trials to verify the potential advantages of LLR over OLR are warranted.

Comparing Open, Laparoscopic and Robotic Liver Resection for Metastatic Colorectal Cancer-A Systematic Review and Network Meta-Analysis.

Colorectal liver metastases (CRLM) can be surgically managed through open resections (OLR), laparoscopic resections (LLR), or robotic liver resections (RLR). However, there is ongoing uncertainty regarding the safety and effectiveness of minimally invasive approaches like LLR and RLR. This study aims to clarify these issues by conducting a network meta-analysis (NMA) to compare outcomes across OLR, LLR and RLR for patients with CRLM. Following the PRISMA-NMA guidelines, the meta-analysis included 13 studies with a combined total of 6582 patients. Of these, 50.6% underwent LLR, 45.3% underwent OLR, and 4.1% underwent RLR. The analysis found no significant differences in R0 resection rates between LLR (odds ratio [OR] 1.03, 95% confidence interval [CI]: 0.84-1.26) and RLR (OR 1.57, 95% CI: 0.98-2.51) when compared to OLR. Additionally, there were no significant differences in disease-free survival (DFS) and overall survival (OS) at 1, 3, and 5 years. Despite these findings, both LLR and RLR were associated with reduced postoperative complication rates (RLR: OR 0.52, 95% CI: 0.32-0.86; LLR: OR 0.50, 95% CI: 0.37-0.68). However, patients undergoing LLR were more likely to require conversion to open surgery compared to those undergoing RLR (OR: 12.46, 95% CI: 2.64-58.67). Furthermore, RLR was associated with a reduced need for blood transfusions (OR: 0.13, 95% CI: 0.05-0.32), and LLR resulted in shorter hospital stays (mean difference: -6.66 days, 95% CI: -11.6 to -1.88 days). This study demonstrates the oncological safety of LLR and RLR approaches for CRLM relative to OLR, with enhanced perioperative outcomes anticipated following minimally invasive resections of CRLM.

Is prolonged operative time associated with postoperative complications in liver surgery? An international multicentre cohort study of 5424 patients.

The relation between operative time and postoperative complications in liver surgery is unclear. The aim of this study is to assess the impact of operative time on the development of postoperative complications in patients who underwent minimally invasive or open liver resections of various anatomical extent and technical difficulty levels. In this retrospective cohort study, patients that underwent a right hemihepatectomy (RH), technically major resection (anatomically minor resection in segment 1, 4a, 7 or 8; TMR) or left lateral sectionectomy (LLS) between 2000 and 2022 were extracted from a multicenter database comprising the prospectively maintained databases of 31 centers in 13 countries. Minimally invasive procedures performed during the learning curve were omitted. Logistic regression models, performed separately for 9 different groups based on stratification by procedure type and allocated surgical approach, were used to assess the association between the fourth quartile of operative time (25% of patients with the longest operative time) and postoperative complications. Overall, 5424 patients were included: 1351 underwent RH (865 open, 373 laparoscopic and 113 robotic), 2821 TMR (1398 open, 1225 laparoscopic and 198 robotic), and 1252 LLS (241 open, 822 laparoscopic and 189 robotic). After adjusting for potential confounders (age, BMI, gender, ASA grade, previous abdominal surgery, disease type and extent, blood loss, Pringle, intraoperative transfusions and incidents), the fourth quartile of operative time, compared to the first three quartiles, was associated with an increased risk of postoperative complications after open, laparoscopic and robotic TMR (aOR 1.35, p = 0.031; aOR 1.74, p = 0.001 and aOR 3.11, p = 0.014, respectively), laparoscopic and robotic RH (aOR 1.98, p = 0.018 and aOR 3.28, p = 0.055, respectively) and solely laparoscopic LLS (aOR 1.69, p = 0.019). A prolonged operative time is associated with an increased risk of postoperative complications, although it remains to be defined if this is a causal relationship.

Open, laparoscopic liver resection and percutaneous thermal ablation in elderly patients with hepatocellular carcinoma: outcomes and therapeutic strategy.

Liver resection and percutaneous thermal ablation (PTA) are considered curative option for hepatocellular carcinoma (HCC). This study aims to compare short- and long-term outcomes between open liver resection (OLR), laparoscopic liver resection (LLR), and PTA in elderly patients with single HCC and to define a liver map for therapeutic strategy according to HCC location and size. A multicenter retrospective study was conducted in 10 European Hospital Center, including 239 consecutive liver resection (OLR and LLR) and PTA in elderly patients ≥ 70years old with single HCC ≤ 30mm. Perioperative data and long-term oncological outcomes were collected and compared between groups before and after propensity score matching. A total of 239 patients were enrolled, distributed as follows: 61 in the ORL group, 88 in the LLR group, and 90 in the PTA group. The hospital stay was longer in OLR and LLR groups compared to the PTA group (6, 5 and 3days, respectively, p < 0.05). Morbidity was lower in the PTA group compared to the OLR group (11 vs. 26%, respectively, p < 0.05). Overall survival (OS) at 5years was significantly higher in the OLR and LLR groups compared to the PTA group (82, 81, and 34%, respectively, p < 0.001). Disease-free survival (DFS) at 5years was also significantly higher in the ORL and LLR groups compared to the PTA group (66, 50 and 20%, respectively, p < 0.001). These results were also confirmed after a propensity score matching analysis between surgery group (OLR and LLR) and the PTA group. PTA was the most used treatment for subcapsular and deep HCC not in contact with vascular structures compared to OLR and LLR. PTA in elderly patients ensures a shorter hospital stay and lower morbidity but worst survival compared to liver resection.

The effectiveness and outcomes of epidural analgesia in patients undergoing open liver resection: a propensity score matching analysis

BackgroundOpen liver resection necessitates a substantial upper abdominal inverted-L incision, resulting in severe pain and compromising patient recovery. Despite the efficacy of epidural analgesia in providing adequate postoperative analgesia, the potential epidural-related adverse effects should be carefully considered. This study aims to compare the efficacy and safety of continuous epidural analgesia and intravenous analgesia in open liver resection.MethodsA retrospective study was conducted, collecting data from patients who underwent open liver resection between 2007 and 2017. Propensity score matching was implemented to mitigate confounding variables, with patients being matched in a 1:1 ratio based on propensity scores. The primary outcome was the comparison of postoperative morphine consumption at 24, 48, and 72 hours between the two groups. Secondary outcomes included pain scores, postoperative outcomes, and epidural-related adverse effects.ResultsA total of 612 patients were included, and after matching, there were 204 patients in each group. Opioid consumption at 24, 48, and 72 hours postoperatively was statistically lower in the epidural analgesia group compared to the intravenous analgesia group (p < 0.001). However, there was no significant difference in pain scores (p = 0.422). Additionally, perioperative hypotension requiring treatment, as well as nausea and vomiting, were significantly higher in the epidural analgesia group compared to the intravenous analgesia group (p < 0.001).ConclusionsEpidural analgesia is superior to intravenous morphine in terms of reducing postoperative opioid consumption within the initial 72 h after open liver resection. Nevertheless, perioperative hypotension, which necessitates management, should be approached with consideration and vigilance.Trial registrationThe study was registered in the Clinical Trials Registry at www.clinicaltrials.gov/, NCT number: NCT06301932.

Safety and Feasibility of Laparoscopic Anatomical Liver Resection for Hepatocellular Carcinoma: A Propensity Score-matched Study.

Laparoscopic anatomical liver resection (LAR) for hepatocellular carcinoma (HCC) is technically demanding. Therefore, this study aimed to compare the perioperative and long-term oncological outcomes of LAR and open anatomical liver resection (OAR) for HCC. We retrospectively analyzed 460 consecutive patients who underwent anatomical liver resection as the initial treatment for primary HCC between January 2010 and February 2024. Patients were categorized into the LAR and OAR groups, and surgical outcomes between the groups were compared using 1:1 propensity score matching (PSM). After PSM, the LAR and OAR groups included 100 patients each. The LAR group exhibited significantly less blood loss (80 vs. 436 ml; p<0.0001), lower transfusion rates (0% vs. 12%; p=0.0002), shorter operative time (345 vs. 398 min; p=0.0009), lower postoperative morbidity rates (6% vs. 34%; p<0.0001), and shorter postoperative hospital stay (8 vs. 15 days; p<0.0001) than the OAR group. The 1-, 3-, and 5-year overall survival rates were 97.7%, 96.2%, and 89.7%, respectively, in the LAR group and 98.0%, 92.7%, and 88.4%, respectively, in the OAR group (p=0.5874). The 1-, 3-, and 5-year recurrence-free survival rates were 93.2%, 75.7%, and 60.7%, respectively, in the LAR group and 86.0%, 64.5%, and 59.1%, respectively, in the OAR group (p=0.2314). LAR showed improvements in perioperative complications, reduced postoperative hospital stay, and comparable recurrence-free and overall survival rates with those of OAR. Therefore, LAR for HCC is considered safe, feasible, and oncologically acceptable in selected patients.

The differential benefit of laparoscopic over open minor liver resection for lesions situated in the anterolateral or posterosuperior segments.

It is well known that laparoscopic liver surgery can offer advantages over open liver surgery in selected patients. However, what type of procedures can benefit most from a laparoscopic approach has been investigated poorly thus far. The aim of this study is thus to define the extent of advantages of laparoscopic over open liver surgery for lesions in the anterolateral (AL) and posterosuperior (PS) segments. In this international multicentre retrospective cohort study, laparoscopic and open minor liver resections for lesions in the AL and PS segments were compared after propensity score matching. The differential benefit of laparoscopy over open liver surgery, calculated using bootstrap sampling, was compared between AL and PS resections and expressed as a Delta of the differences. After matching, 3,040 AL and 2,336 PS resections were compared, encompassing open and laparoscopic procedures in a 1:1 ratio. AL and PS laparoscopic liver resections were more advantageous in comparison to open in terms of blood loss, transfusion rate, complications, and length of stay. However, AL resections benefitted more from laparoscopy than PS in terms of overall and severe complications (D-difference were 4.8%, P=0.046 and 3%, P=0.046) and blood loss (D-difference was 195 mL, P<0.001). Similar results were observed in the subset for high-volume centres, while in recent years no significant differences were found in the differential benefit between AL and PS segments. The advantage of laparoscopic over open liver surgery is greater in the AL segments than in the PS segments.

Protective Effect of Minimally Invasive Approach on Postoperative Peak Transaminase Following Liver Resection: A Single-Center Propensity Score-Based Analysis.

Postoperative serum ALT levels are one of the most frequently used marker to detect liver tissue damage following liver resection. The aim of this study was to evaluate if minimally invasive liver surgery (MILS) may result in less hepatic injury than open hepatectomy by assessing the differences of postoperative ALT levels. Patients who underwent MILS between 2009 and 2019 at our unit were included and compared with open liver resections. Median ALT levels was measured on postoperative day (POD) 1, 3 and 5. Postoperative peak transaminase (PPT) of ALT was determined on POD 1. The stabilized inverse probability treatment weighing (SIPTW) process was used to balance the two groups. A multivariable logistic regression analysis was used to analyze factors associated with high PPT. After SIPTW, 292 MILS were compared with 159 open resections. Median ALT levels on POD 1, 3 and 5 were significantly higher in the open group than in the MILS group (301 vs. 187, p = 0.002; 180 vs. 121, p < 0.0001; 104 vs. 60, p < 0.0001; respectively). At the multivariable logistic regression analysis, MILS showed a protective effect for high PPT. MILS was associated with significantly lower postoperative ALT levels compared with open liver resections. MILS showed a protective effect for high PPT.

Laparoscopic versus open liver resection for colorectal liver metastasis: an umbrella review.

This study comprehensively compared laparoscopic liver resection (LLR) to open liver resection (OLR) in treating colorectal cancer liver metastasis (CRLM). A systematic review of relevant literature was conducted to assess a range of crucial surgical and oncological outcomes. Findings indicate that minimally invasive surgery (MIS) did not significantly prolong the duration of surgery compared to open liver resection and notably demonstrated lower blood transfusion rates and reduced intraoperative blood loss. While some studies favored MIS for its lower complication rates, others did not establish a statistically significant difference. One study identified a lower post-operative mortality rate in the MIS group. Furthermore, MIS consistently correlated with shorter hospital stays, indicative of expedited post-operative recovery. Concerning oncological outcomes, while certain meta-analyses reported a lower rate of cancer recurrence in the MIS group, others found no significant disparity. Overall survival and disease-free survival remained comparable between the MIS and open liver resection groups. The analysis emphasizes the potential advantages of LLR in terms of surgical outcomes and aligns with existing literature findings in this field. [website], identifier [registration number].

IRON: A retrospective international multicenter study on robotic versus laparoscopic versus open approach in gallbladder cancer

ObjectiveFor patients with T1b gallbladder cancer or greater, an adequate lymphadenectomy should include at least 6 nodes. Studies comparing short- and long-term outcomes of the open approach with those of laparoscopy and robotic approaches are limited, with small sample sizes, and there are none comparing laparoscopic and robotic approaches. This study compared patients who underwent robotic, laparoscopic, and open resection of gallbladder cancer, evaluating short- and long-term outcomes. MethodsWe conducted a multicenter retrospective study of patients with T1b gallbladder cancer or greater (excluding combined organ resection and T4) who underwent open, laparoscopic, and robotic liver resection and lymphadenectomy between January 2012 and December 2022. The 3 groups were matched in terms of patient baseline and disease characteristics based on propensity score matching, comparing robotic with open and robotic with laparoscopic groups. ResultsWe enrolled 575 patients from 37 institutions. After propensity score matching, the median number of harvested nodes was higher in the robotic group than in the open (7 vs 5; P = .0150) and laparoscopic groups (7 vs 4; P < .001). The Pringle maneuver time was shorter with robotic resection than with laparoscopy (38 vs 59 minutes; P = .0034), and the robotic group also had a lower conversion rate (3% vs 14%, respectively; P = .005) and less estimated blood loss than open and laparoscopic resections. The perioperative morbidity and mortality rates did not differ. The robotic and laparoscopic approaches were associated with faster functional recovery than the open group. In the multivariate analysis, the factors related to the retrieval of at least 6 nodes were the robotic approach over open (odds ratio, 5.1529) and over laparoscopy (odds ratio, 6.7289) and the center experience (≥20 minimally invasive liver resections/year) (odds ratio, 4.962). After a mean follow-up of 42.6 months, overall survival and disease-free survival were not different between groups. ConclusionCompared with open and laparoscopic surgeries, the robotic approach for gallbladder cancer performed in a center with appropriate experience in minimally invasive surgery can provide adequate node retrieval.

Comparing laparoscopic and open resection in elderly hepatocellular carcinoma: a systematic review and meta-analysis.

Laparoscopic liver resection (LLR) has been accepted as a safe and effective treatment for hepatocellular carcinoma (HCC). However, its impact on elderly patients remains uncertain. This study aimed to compare the efficacy and safety of LLR with open liver resection (OLR) in elderly HCC patients. We conducted a search across the Ovid-Medline, Ovid-EMBASE, and Cochrane Library to identify comparative studies involving primary HCC in elderly patients (≥65 years). Efficacy-related outcomes encompassed overall survival (OS) and disease-free survival (DFS), while safety-related outcomes included post-operative mortality, complications, and length of stay (LOS). We identified nine eligible cohort studies comprising 1,599 patients. LLR demonstrated comparable 3- and 5-year DFS [hazard ratio (HR) =1.00, 95% confidence interval (CI): 0.98-1.02; HR =1.02, 95% CI: 0.99-1.05] and 3- and 5-year OS (HR =1.01, 95% CI: 0.99-1.02; HR =1.02, 95% CI: 0.99-1.06, respectively) compared to OLR. In terms of safety, there was no significant difference between LLR and OLR in in-hospital mortality [odds ratio (OR) =0.19; 95% CI: 0.02-1.69], 30-day mortality (OR =0.33; 95% CI: 0.03-3.20), and 90-day mortality (OR =0.70; 95% CI: 0.32-1.53). Additionally, LLR presented fewer overall complications (OR =0.53; 95% CI: 0.41-0.67), a lower rate of major complications (OR =0.51; 95% CI: 0.35-0.74), a reduced incidence of liver failure (OR =0.56; 95% CI: 0.33-0.94), and a shorter LOS compared to OLR (mean difference: -14.47 days). LLR exhibited comparable clinical efficacy and superior safety and fewer complications when compared to OLR in elderly patients with HCC requiring surgery.

The predictors of intra-operative surgical expenses in liver resection for hepatocellular carcinoma

Abstract Background This study aimed to clarify the expenses associated with various items and predictors of intraoperative expenses in liver resection for hepatocellular carcinoma (HCC). Materials and Methods A total of 562 patients with HCC who underwent liver resection from January 2015 to December 2019 were enrolled in this retrospective study. The direct variables of total intraoperative expenses were the summation of surgeon’s fee, anesthetic fee, fees for pharmacy, and disposable supplies, which were analyzed based on surgeons’ seniority, patients’ demographic features and comorbidity, clinical features of HCC, and complexity of surgery and surgical approach. Results Of the total cost, 43.3% accounted for expenses of disposing supplies, 32.8% for surgeons’ fees, 15.9% for anesthetic fees, and 8.12% for pharmacy fees. A hierarchical model of multivariate regression analysis showed that the total expenses and that of disposable supplies were significantly higher in surgeons with seniority of over 26 years (p &lt; 0.001) and those having a specialization of robotic surgery (p &lt; 0.001). Further, the complexity and robotic approach of surgery predicted the total expenses (R2 = 0.862, p &lt; 0.001). Robotic approach and its disposable supplies and major liver resection increased by 93.2% and 20.1% (p &lt; 0.001) of total expenses when compared to open liver resection or partial liver resection, respectively. Conclusion The study found that the robotic approach, disposable supplies, and complexity of surgery were the most important predictors of total intraoperative expenses for patients with HCC. Therefore, a cost-effectiveness analysis should be conducted to define the surgical value of the robotic approach for HCC resection.

Initial laparoscopic liver resection is associated with reduced adhesions and transfusions at the time of salvage liver transplantation

BackgroundLaparoscopic liver resection (LLR) has been associated with improved patient recovery as well as reduced postoperative adhesions compared to open LR (OLR) and could therefore facilitate redo liver surgery. LLR prior to liver transplantation (LT) is increasingly performed, LT being saved for HCC recurrence. LT is still performed by open surgery due to vascular reconstructions and underlying liver chronic disease. We evaluated the impact of laparoscopic approach for LR prior to LT in terms of intraoperative transfusions, adhesions severity and outcome. MethodsData from all patients who underwent a LT after LR in two French high-volume tertiary centers were retrospectively reviewed. The impact of LLR on per operative and postoperative outcome was assessed using logistic regression. Results170 patients were included, 43 patients in the LLR group and 127 in the OLR group. Preoperative characteristics were comparable between both groups, except LLR group included more patients with “very early-stage” BCLC tumors than OLR group (51% vs. 33%, p = 0.02) and less anatomical resections (54% vs. 75%, p = 0.015). During LT, the transfusion rate was significantly higher in the OLR group (71.4% vs 44.2%, p = 0.002) as well as the proportion of type III adhesions according to OLSG classification (p < 0.001). Multivariate analysis found LLR to be an independent protective factor for adhesions and transfusion (p = 0.001 and p = 0.03 respectively). ConclusionLaparoscopic liver resection was associated with reduced postoperative adhesions and transfusion requirements during subsequent liver transplantation.

Outcomes after laparoscopic or open liver resection for nonalcoholic fatty liver disease-associated hepatocellular carcinoma: a propensity score-matching study.

Laparoscopic liver resection (LLR) is rapidly gaining popularity; however, its efficacy for nonalcoholic fatty liver disease (NAFLD)-associated hepatocellular carcinoma (HCC) (NAFLD-HCC) has been not evaluated. The purpose of this study was to compare short- and long-term outcomes between LLR and open liver resection (OLR) among patients with NAFLD-HCC. We used a single-institution database to analyze data for patients who underwent LLR or OLR for NAFLD-HCC from January 2007 to December 2022. We performed propensity score-matching analyses to compare overall postoperative complications, major morbidities, duration of surgery, blood loss, transfusion, length of stay, recurrence, and survival between the two groups. Among 210 eligible patients, 46 pairs were created by propensity score matching. Complication rates were 28% for OLR and 11% for LLR (p = 0.036). There were no significant differences in major morbidities (15% vs. 8.7%, p = 0.522) or duration of surgery (199 min vs. 189 min, p = 0.785). LLR was associated with a lower incidence of blood transfusion (22% vs. 4.4%, p = 0.013), less blood loss (415 vs. 54 mL, p < 0.001), and shorter postoperative hospital stay (9 vs. 6 days, p < 0.001). Differences in recurrence-free survival and overall survival between the two groups were not statistically significant (p = 0.222 and 0.301, respectively). LLR was superior to OLR for NAFLD-HCC in terms of overall postoperative complications, blood loss, blood transfusion, and postoperative length of stay. Moreover, recurrence-free survival and overall survival were comparable between LLR and OLR. Although there is a need for careful LLR candidate selection according to tumor size and location, LLR can be regarded as a preferred treatment for NAFLD-HCC over OLR.

Short-term Outcomes of Laparoscopic Versus Open Liver Resection in the Elderly: A Propensity Score-matched Analysis.

With the aging of the population, there is a rising proportion of elderly patients undergoing liver resection. However, the safety and efficacy of laparoscopic liver resection (LLR) in the elderly have not yet been established. In this study, we compared the short-term results of LLR and open liver resection (OLR) in elderly patients using propensity score matched (PSM) analysis. The study comprised 237 elderly patients aged 65 years and older who had undergone liver resection between 2015 to 2021, excluding biliary and vascular reconstruction and simultaneous surgeries other than liver resection. We conducted PSM analysis for baseline characteristics (age, sex, BMI, ASA-PS, disease, procedure, tumor size, and number of tumors) to eliminate potential selection bias. We then compared short-term postoperative outcomes between LLR and OLR groups in patients selected by PSM analysis. Applying PSM analysis, 90 cases each were selected for the LLR and OLR groups. The LLR group had a significantly lower complication rate (Clavien-Dindo: CD ≥II) (19% vs. 33%, p=0.03), especially bile leakage (CD ≥II) (0% vs. 6.7%, p=0.03) compared with those in the OLR group. In addition, a shorter operation time (244 min vs. 351 min, p<0.01), less blood loss (150 ml vs. 335 ml, p<0.01), and shorter hospital stay (8 days vs. 12 days, p<0.01) were observed in the LLR group. No operative or in-hospital deaths were observed in both groups. LLR can be safely performed in elderly patients and offers better short-term outcomes.

Does the Surgical Approach Affect the Incidence of Post-Hepatectomy Liver Failure in Cirrhotic Patients? An Analysis of the NSQIP Database.

Background: The association between surgical approach and post-hepatectomy liver failure (PHLF) in cirrhotic patients is poorly understood. We hypothesize that patients will have similar rates of liver failure regardless of whether they undergo minimally invasive liver resection (MILR) or open liver resection (OLR) in major liver resections. In contrast, there will be lower rates of PHLF in patients undergoing minor hepatectomy via the MILR approach.Methods: Propensity score matching was used to analyze regression by matching the MILR to the OLR cohort. Patient demographics from the American College of Surgeons National Surgical Quality Improvement Program, including race, age, gender, and ethnicity, were matched. Chronic obstructive pulmonary disease, congestive heart failure, smoking, hypertension, diabetes, renal failure, dyspnea, dialysis dependence, body mass index, and American Society of Anesthesiologists (ASA) classification (>ASA III) were among the preoperative patient characteristics subject to matching. PHLF (Grade A vs B. vs C) was our primary outcome measure.Results: A total of 2129 cirrhotic patients were included in the study. In the minor hepatectomy group, patients undergoing an OLR were more likely to get discharged to a facility (7.0% vs 4.4%; P = .03), had greater hospital length of stay (5 vs 3 days; P = .02), and had a greater need for invasive postoperative interventions (10.7% vs 4.6%; P < .01). They were also noted to have higher rates of organ space superficial surgical infections (SSIs) (7.3% vs 3.7%; P = .003), Clostridium difficile infection (.9% vs .1%; P = .05), renal insufficiency (2.1% vs .1%; P < .01), unplanned intubations (3.1% vs 1.4%; P = .03), and Grade C liver failure (2.3% vs .9%; P = .03).Conclusion: A higher incidence of PHLF grade C was found in patients undergoing OLR in the minor hepatectomy group. Therefore, in cirrhotic patients who can tolerate minimally invasive approaches, MILR should be offered to prevent postoperative complications as part of their optimization plan.

Commentary on "Comparison between laparoscopic liver resection and open liver resection in patients with hepatocellular carcinoma with portal vein tumor thrombosis".

Commentary on "Comparison between laparoscopic liver resection and open liver resection in patients with hepatocellular carcinoma with portal vein tumor thrombosis".