Laparoscopic Liver Resection Headed for Mainstream

SAN ANTONIO – Laparoscopic liver resection provides significant intraoperative and postoperative benefits, compared with open hepatic resection, in patients with benign and malignant tumors and it does not compromise 5-year outcomes in hepatocellular carcinoma or colorectal cancer metastases, said Dr. David A. Geller, codirector of the liver cancer center at the University of Pittsburgh Medical Center.

Not yet considered standard of care, "laparoscopic hepatic resection [LHR] has now been performed in more than 4,000 patients worldwide, and the benefits when compared with open hepatic resection [OHR] include decreased operating room time, less pain, less narcotic use, shorter length of stay, less blood loss when matched for size of tumor and extent of the operation performed, faster oral intake, and a Band-Aid–sized incision," Dr. Geller concluded from a review of the available literature. The studies included meta-analyses, case cohort matched series, and single-center series from more than 20 centers.

"Most importantly, there are no oncologic disadvantages," he said. "If we were giving patients a small incision and shortening their recovery but sacrificing margins or recurrences, then it wouldn’t be worthwhile."

The first comprehensive literature review on the LHR procedure was published in the Annals of Surgery in 2009; it showed the procedure to be "safe with acceptable morbidity and mortality for both minor and major hepatic resections," said Dr. Geller, who coauthored the study (Ann. Surg. 2009;250:842-8).

Of 2,804 minimally invasive liver resections included in that analysis, the overall mortality was 0.3%, and "morbidity was 10.5% with no intraoperative deaths," Dr. Geller reported at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

For cancer resections, which constituted 50% of the total resections, "negative surgical margins were achieved in 82%-100% of the reported series, and the overall and disease-free survival at 3 years in the colorectal metastasis patients and at 5 years in the hepatocellular carcinoma patients matched – or was better than – that seen in open liver resection series," he said.

Acknowledging the likelihood of a bias for carefully selected patients with laparoscopic procedures, "the results still confirm that in well-selected patients, and in the hands of technically skilled surgeons who have training in both minimally invasive surgery and formal liver procedures, it is a safe operation," Dr. Geller concluded.

The following studies corroborate and extend the early findings, he said:

• An updated meta-analysis of relevant studies evaluating long-term outcomes of LHR and OHR for benign and malignant tumors demonstrated that patients undergoing LHR for malignant tumors had a significantly reduced hazard ratio for death, less operative blood loss, and fewer postoperative complications than did patients in the OHR group, with no significant difference in the rate of recurrence compared with the OHR patients (Arch. Surg. 2010;145:1109-18).

• In a review of 31 case-cohort matched studies that directly compared LHR with OHR in nearly 2,500 patients, and an institutional series of 314 patients, Dr. Geller and colleagues showed that, in addition to the previously reported safety and efficacy findings and patient benefits, the minimally invasive approach was economically advantageous, despite the increased cost associated with disposable instruments, because of the reduced incidence of complications and significantly shorter hospital stays (Arch. Surg. 2011;146:348-56).

There are currently no level 1, randomized, controlled trials comparing LHR and OHR, "and there probably never will be, both because it would be difficult to accrue enough patients to detect a difference in the complications and because it’s very much patient driven, and patients are unlikely to choose to undergo the open procedure when the reported outcomes of the minimally invasive procedure have been so positive," said Dr. Geller.

"The body of literature available to date indicates that, in experienced hands, [LHR] for both benign and malignant lesions is safe and feasible, is associated with significant short-term patient benefits, is economically reasonable, and does not compromise oncologic principles." As such, he noted, "laparoscopic hepatic resection should be considered an important tool in the liver resection armamentarium."

Dr. Geller reported having no relevant financial conflicts of interest.

SAN ANTONIO – Laparoscopic liver resection provides significant intraoperative and postoperative benefits, compared with open hepatic resection, in patients with benign and malignant tumors and it does not compromise 5-year outcomes in hepatocellular carcinoma or colorectal cancer metastases, said Dr. David A. Geller, codirector of the liver cancer center at the University of Pittsburgh Medical Center.

Not yet considered standard of care, "laparoscopic hepatic resection [LHR] has now been performed in more than 4,000 patients worldwide, and the benefits when compared with open hepatic resection [OHR] include decreased operating room time, less pain, less narcotic use, shorter length of stay, less blood loss when matched for size of tumor and extent of the operation performed, faster oral intake, and a Band-Aid–sized incision," Dr. Geller concluded from a review of the available literature. The studies included meta-analyses, case cohort matched series, and single-center series from more than 20 centers.

"Most importantly, there are no oncologic disadvantages," he said. "If we were giving patients a small incision and shortening their recovery but sacrificing margins or recurrences, then it wouldn’t be worthwhile."

The first comprehensive literature review on the LHR procedure was published in the Annals of Surgery in 2009; it showed the procedure to be "safe with acceptable morbidity and mortality for both minor and major hepatic resections," said Dr. Geller, who coauthored the study (Ann. Surg. 2009;250:842-8).

Of 2,804 minimally invasive liver resections included in that analysis, the overall mortality was 0.3%, and "morbidity was 10.5% with no intraoperative deaths," Dr. Geller reported at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

For cancer resections, which constituted 50% of the total resections, "negative surgical margins were achieved in 82%-100% of the reported series, and the overall and disease-free survival at 3 years in the colorectal metastasis patients and at 5 years in the hepatocellular carcinoma patients matched – or was better than – that seen in open liver resection series," he said.

Acknowledging the likelihood of a bias for carefully selected patients with laparoscopic procedures, "the results still confirm that in well-selected patients, and in the hands of technically skilled surgeons who have training in both minimally invasive surgery and formal liver procedures, it is a safe operation," Dr. Geller concluded.

The following studies corroborate and extend the early findings, he said:

• An updated meta-analysis of relevant studies evaluating long-term outcomes of LHR and OHR for benign and malignant tumors demonstrated that patients undergoing LHR for malignant tumors had a significantly reduced hazard ratio for death, less operative blood loss, and fewer postoperative complications than did patients in the OHR group, with no significant difference in the rate of recurrence compared with the OHR patients (Arch. Surg. 2010;145:1109-18).

• In a review of 31 case-cohort matched studies that directly compared LHR with OHR in nearly 2,500 patients, and an institutional series of 314 patients, Dr. Geller and colleagues showed that, in addition to the previously reported safety and efficacy findings and patient benefits, the minimally invasive approach was economically advantageous, despite the increased cost associated with disposable instruments, because of the reduced incidence of complications and significantly shorter hospital stays (Arch. Surg. 2011;146:348-56).

There are currently no level 1, randomized, controlled trials comparing LHR and OHR, "and there probably never will be, both because it would be difficult to accrue enough patients to detect a difference in the complications and because it’s very much patient driven, and patients are unlikely to choose to undergo the open procedure when the reported outcomes of the minimally invasive procedure have been so positive," said Dr. Geller.

"The body of literature available to date indicates that, in experienced hands, [LHR] for both benign and malignant lesions is safe and feasible, is associated with significant short-term patient benefits, is economically reasonable, and does not compromise oncologic principles." As such, he noted, "laparoscopic hepatic resection should be considered an important tool in the liver resection armamentarium."

Dr. Geller reported having no relevant financial conflicts of interest.

SAN ANTONIO – Laparoscopic liver resection provides significant intraoperative and postoperative benefits, compared with open hepatic resection, in patients with benign and malignant tumors and it does not compromise 5-year outcomes in hepatocellular carcinoma or colorectal cancer metastases, said Dr. David A. Geller, codirector of the liver cancer center at the University of Pittsburgh Medical Center.

Not yet considered standard of care, "laparoscopic hepatic resection [LHR] has now been performed in more than 4,000 patients worldwide, and the benefits when compared with open hepatic resection [OHR] include decreased operating room time, less pain, less narcotic use, shorter length of stay, less blood loss when matched for size of tumor and extent of the operation performed, faster oral intake, and a Band-Aid–sized incision," Dr. Geller concluded from a review of the available literature. The studies included meta-analyses, case cohort matched series, and single-center series from more than 20 centers.

"Most importantly, there are no oncologic disadvantages," he said. "If we were giving patients a small incision and shortening their recovery but sacrificing margins or recurrences, then it wouldn’t be worthwhile."

The first comprehensive literature review on the LHR procedure was published in the Annals of Surgery in 2009; it showed the procedure to be "safe with acceptable morbidity and mortality for both minor and major hepatic resections," said Dr. Geller, who coauthored the study (Ann. Surg. 2009;250:842-8).

Of 2,804 minimally invasive liver resections included in that analysis, the overall mortality was 0.3%, and "morbidity was 10.5% with no intraoperative deaths," Dr. Geller reported at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

For cancer resections, which constituted 50% of the total resections, "negative surgical margins were achieved in 82%-100% of the reported series, and the overall and disease-free survival at 3 years in the colorectal metastasis patients and at 5 years in the hepatocellular carcinoma patients matched – or was better than – that seen in open liver resection series," he said.

Acknowledging the likelihood of a bias for carefully selected patients with laparoscopic procedures, "the results still confirm that in well-selected patients, and in the hands of technically skilled surgeons who have training in both minimally invasive surgery and formal liver procedures, it is a safe operation," Dr. Geller concluded.

The following studies corroborate and extend the early findings, he said:

• An updated meta-analysis of relevant studies evaluating long-term outcomes of LHR and OHR for benign and malignant tumors demonstrated that patients undergoing LHR for malignant tumors had a significantly reduced hazard ratio for death, less operative blood loss, and fewer postoperative complications than did patients in the OHR group, with no significant difference in the rate of recurrence compared with the OHR patients (Arch. Surg. 2010;145:1109-18).

• In a review of 31 case-cohort matched studies that directly compared LHR with OHR in nearly 2,500 patients, and an institutional series of 314 patients, Dr. Geller and colleagues showed that, in addition to the previously reported safety and efficacy findings and patient benefits, the minimally invasive approach was economically advantageous, despite the increased cost associated with disposable instruments, because of the reduced incidence of complications and significantly shorter hospital stays (Arch. Surg. 2011;146:348-56).

There are currently no level 1, randomized, controlled trials comparing LHR and OHR, "and there probably never will be, both because it would be difficult to accrue enough patients to detect a difference in the complications and because it’s very much patient driven, and patients are unlikely to choose to undergo the open procedure when the reported outcomes of the minimally invasive procedure have been so positive," said Dr. Geller.

"The body of literature available to date indicates that, in experienced hands, [LHR] for both benign and malignant lesions is safe and feasible, is associated with significant short-term patient benefits, is economically reasonable, and does not compromise oncologic principles." As such, he noted, "laparoscopic hepatic resection should be considered an important tool in the liver resection armamentarium."

Dr. Geller reported having no relevant financial conflicts of interest.