Leonid Barkhatov

Laparoscopic Versus Open Liver Resection for Colorectal Metastases in Elderly and Octogenarian Patients: A Multicenter Propensity Score Based Analysis of Short- and Long-term Outcomes

Objective: This study aims to compare the perioperative and oncological outcomes of laparoscopic and open liver resection for colorectal liver metastases in the elderly. Background: Laparoscopic liver resection has been associated with less morbidity and similar oncological outcomes to open liver resection for colorectal liver metastases (CRLMs). It has been reported that these benefits continue to be observed in elderly patients. However, in previous studies, patients over 70 or 75 years were considered as a single, homogenous population raising questions regarding the true impact of the laparoscopic approach on this diverse group of elderly patients. Method: Prospectively maintained databases of all patients undergoing liver resection for CRLM in 5 tertiary liver centers were included. Those over 70-years old were selected for this study. The cohort was divided in 3 subgroups based on age. A comparative analysis was performed after the implementation of propensity score matching on the 2 main cohorts (laparoscopic and open groups) and also on the study subgroups. Results: A total of 775 patients were included in the study. After propensity score matching 225 patients were comparable in each of the main groups. Lower blood loss (250 vs 400 mL, P = 0.001), less overall morbidity (22% vs 39%, P = 0.001), shorter High Dependency Unit (2 vs. 6 days, P = 0.001), and total hospital stay (5 vs. 8 days, P = 0.001) were observed after laparoscopic liver resection. Comparable rates of R0 resection (88% vs 88%, P = 0.999), median recurrence-free survival (33 vs 27 months, P = 0.502), and overall survival (51 vs 45 months, P = 0.671) were observed. The advantages seen with the laparoscopic approach were reproduced in the 70 to 74-year old subgroup; however there was a gradual loss of these advantages with increasing age. Conclusions: In patients over 70 years of age laparoscopic liver resection, for colorectal liver metastases, offers significant lower morbidity, and a shorter hospital stay with comparable oncological outcomes when compared with open liver resection. However, the benefits of the laparoscopic approach appear to fade with increasing age, with no statistically significant benefits in octogenarians except for a lower High Dependency Unit stay.

Margin status after laparoscopic resection of colorectal liver metastases: does a narrow resection margin have an influence on survival and local recurrence?

OBJECTIVES Recent studies of margin-related recurrence have raised questions on the necessity of ensuring wide resection margins in the resection of colorectal liver metastases. The aim of the current study was to determine whether resection margins of 10 mm provide a survival benefit over narrower resection margins. METHODS A total of 425 laparoscopic liver resections were carried out in 351 procedures performed in 317 patients between August 1998 and April 2012. Primary laparoscopic liver resections for colorectal metastases were included in the study. Two-stage resections, procedures accompanied by concomitant liver ablations and one case of perioperative mortality were excluded. A total of 155 eligible patients were classified into four groups according to resection margin width: Group 1, margins of < 1 mm [n = 33, including 17 patients with positive margins (Group 1a)]; Group 2, margins of 1 mm to < 3 mm (n = 31); Group 3, margins of ≥ 3 mm to <10 mm (n = 55), and Group 4, margins of ≥ 10 mm (n = 36). Perioperative and survival data were compared across the groups. Median follow-up was 31 months (range: 2-136 months). RESULTS Perioperative outcomes were similar in all groups. Unfavourable intraoperative incidents occurred in 9.7% of procedures (including 3.2% of conversions). Postoperative complications developed in 11.0% of patients. Recurrence in the resection bed developed in three (1.9%) patients, including two (6.1%) patients in Group 1. Rates of actuarial 5-year overall, disease-free and recurrence-free survival were 49%, 41% and 33%, respectively. Median survival was 65 months. Margin status had no significant impact on patient survival. The Basingstoke Predictive Index (BPI) generally underestimated survival. This underestimation was especially marked in Group 1 when postoperative BPI was applied. CONCLUSIONS Patients with margins of <1 mm achieved survival comparable with that in patients with margins of ≥ 10 mm. When modern surgical equipment that generates an additional coagulation zone is applied, the association between resection margin and survival may not be apparent. Further studies in this field are required. Postoperative BPI, which includes margin status among the core factors predicting postoperative survival, seems to be less precise than preoperative BPI.

Laparoscopic Versus Open Resection for Colorectal Liver Metastases: The OSLO-COMET Randomized Controlled Trial.

Objective: To perform the first randomized controlled trial to compare laparoscopic and open liver resection. Summary Background Data: Laparoscopic liver resection is increasingly used for the surgical treatment of liver tumors. However, high-level evidence to conclude that laparoscopic liver resection is superior to open liver resection is lacking. Methods: Explanatory, assessor-blinded, single center, randomized superiority trial recruiting patients from Oslo University Hospital, Oslo, Norway from February 2012 to January 2016. A total of 280 patients with resectable liver metastases from colorectal cancer were randomly assigned to undergo laparoscopic (n = 133) or open (n = 147) parenchyma-sparing liver resection. The primary outcome was postoperative complications within 30 days (Accordion grade 2 or higher). Secondary outcomes included cost-effectiveness, postoperative hospital stay, blood loss, operation time, and resection margins. Results: The postoperative complication rate was 19% in the laparoscopic-surgery group and 31% in the open-surgery group (12 percentage points difference [95% confidence interval 1.67–21.8; P = 0.021]). The postoperative hospital stay was shorter for laparoscopic surgery (53 vs 96 hours, P < 0.001), whereas there were no differences in blood loss, operation time, and resection margins. Mortality at 90 days did not differ significantly from the laparoscopic group (0 patients) to the open group (1 patient). In a 4-month perspective, the costs were equal, whereas patients in the laparoscopic-surgery group gained 0.011 quality-adjusted life years compared to patients in the open-surgery group (P = 0.001). Conclusions: In patients undergoing parenchyma-sparing liver resection for colorectal metastases, laparoscopic surgery was associated with significantly less postoperative complications compared to open surgery. Laparoscopic resection was cost-effective compared to open resection with a 67% probability. The rate of free resection margins was the same in both groups. Our results support the continued implementation of laparoscopic liver resection.

The Southampton Consensus Guidelines for Laparoscopic Liver Surgery: From Indication to Implementation

Objective: The European Guidelines Meeting on Laparoscopic Liver Surgery was held in Southampton on February 10 and 11, 2017 with the aim of presenting and validating clinical practice guidelines for laparoscopic liver surgery. Background: The exponential growth of laparoscopic liver surgery in recent years mandates the development of clinical practice guidelines to direct the specialitys continued safe progression and dissemination. Methods: A unique approach to the development of clinical guidelines was adopted. Three well-validated methods were integrated: the Scottish Intercollegiate Guidelines Network methodology for the assessment of evidence and development of guideline statements; the Delphi method of establishing expert consensus, and the AGREE II-GRS Instrument for the assessment of the methodological quality and external validation of the final statements. Results: Along with the committee chairman, 22 European experts; 7 junior experts and an independent validation committee of 11 international surgeons produced 67 guideline statements for the safe progression and dissemination of laparoscopic liver surgery. Each of the statements reached at least a 95% consensus among the experts and were endorsed by the independent validation committee. Conclusion: The European Guidelines Meeting for Laparoscopic Liver Surgery has produced a set of clinical practice guidelines that have been independently validated for the safe development and progression of laparoscopic liver surgery. The Southampton Guidelines have amalgamated the available evidence and a wealth of experts’ knowledge taking in consideration the relevant stakeholders’ opinions and complying with the international methodology standards.

Evolution of Laparoscopic Liver Surgery from Innovation to Implementation to Mastery: Perioperative and Oncologic Outcomes of 2,238 Patients from 4 European Specialized Centers

BACKGROUND First seen as an innovation for select patients, laparoscopic liver resection (LLR) has evolved since its introduction, resulting in worldwide use. Despite this, it is still limited mainly to referral centers. The aim of this study was to evaluate a large cohort undergoing LLR from 2000 to 2015, focusing on the technical approaches, perioperative and oncologic outcomes, and evolution of practice over time. STUDY DESIGN The demographics and indications, intraoperative, perioperative, and oncologic outcomes of 2,238 patients were evaluated. Trends in practice and outcomes over time were assessed. RESULTS The percentage of LLR performed yearly has increased from 5% in 2000 to 43% in 2015. Pure laparoscopy was used in 98.3% of cases. Wedge resections were the most common operation; they were predominant at the beginning of LLR and then decreased and remained steady at approximately 53%. Major hepatectomies were initially uncommon, then increased and reached a stable level at approximately 16%. Overall, 410 patients underwent resection in the posterosuperior segments; these were more frequent with time, and the highest percentage was in 2015 (26%). Blood loss, operative time, and conversion rate improved significantly with time. The 5-year overall survival rates were 73% and 54% for hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM), respectively. The 5-year, recurrence-free survival rates were 50% and 37% for HCC and CRLM, respectively. CONCLUSIONS Since laparoscopy was introduced, a long implementation process has been necessary to allow for standardization and improvement in surgical care, mastery of the technique, and the ability to obtain good perioperative results with safe oncologic outcomes.

Outcome after laparoscopic and open resections of posterosuperior segments of the liver

Laparoscopic resection of posterosuperior (PS) segments of the liver is hindered by limited visualization and curvilinear resection planes. The aim of this study was to compare outcomes after open and laparoscopic liver resections of PS segments.

Conversion for Unfavorable Intraoperative Events Results in Significantly Worst Outcomes During Laparoscopic Liver Resection: Lessons Learned From a Multicenter Review of 2861 Cases

Objective: To investigate the risk factors for conversion during laparoscopic liver resection and its effect on patient outcome in a large cohort of patients. Additional analysis of outcomes in patients who required conversion for unfavorable intraoperative findings and conversion for unfavorable intraoperative events will be performed to establish if the cause of conversion effects outcome. Summary Background Data: Multiple previous studies demonstrate that laparoscopic liver surgery reduces intraoperative blood loss, hospital stay, and morbidity while maintaining comparable oncological and survival outcomes when compared with open liver resections. However, limited information is available regarding the possible sequelae of conversion to open surgery, especially with regards to cause of conversion. Methods: A retrospective analysis of 2861 cases from prospectively maintained databases of 7 tertiary liver centers across Europe was performed. Results: Neo-adjuvant chemotherapy, previous liver resection(s), resections for malignant lesions, postero-superior location, and the extent of the resection are associated with an increased risk of conversion. Patients who require conversion have longer operations with higher blood loss; a longer HDU and total hospital stay, increased frequency and severity of complications and higher 30- and 90-day mortality. Patients who had an elective conversion for an unfavorable intraoperative finding had better outcomes than patients who had an emergency conversion secondary to an unfavorable intraoperative event in terms of HDU and total hospital stay, severity of complication, and 90-day mortality. Conclusions: Our study highlights the risk factors for conversion and suggests that conversion for unfavorable intraoperative events is associated with worse outcomes.

Perioperative outcomes and survival in elderly patients undergoing laparoscopic distal pancreatectomy

The outcomes following laparoscopic distal pancreatectomy (LDP) in elderly patients have not been widely reported to date. This study aimed to analyze perioperative and oncologic outcomes in patients aged ≥70 years (elderly group) and compare with those <70 years (non‐elderly group).

The impact of laparoscopic versus open colorectal cancer surgery on subsequent laparoscopic resection of liver metastases: a multicenter study

BACKGROUND Laparoscopic liver surgery is expanding. Most laparoscopic liver resections for colorectal carcinoma metastases are performed subsequent to the resection of the colorectal primary, raising concerns about the feasibility and safety of advanced laparoscopic liver surgery in the context of an abdomen with possible postoperative adhesions. The aim was to compare the outcome of laparoscopic hepatectomy for colorectal metastases after open versus laparoscopic colorectal surgery. METHODS This observational, multicenter study reviewed 394 patients undergoing laparoscopic minor and major liver resection for colorectal carcinoma metastases. Main outcome measures were intraoperative unfavorable incidents and short-term results in patients who had previous open versus laparoscopic colorectal cancer surgery. RESULTS Three hundred six patients (78%) had prior open and 88 (22%) had prior laparoscopic colorectal resection. Laparoscopic major hepatectomies were undertaken in 63 (16%). Intraoperative unfavorable incidents during laparoscopic liver surgery were significantly higher among patients who had prior open colorectal surgery (26%) compared with the laparoscopic group (14%; P = .017). Positive resection margins and postoperative complications were not associated with the approach adopted for the resection of the primary cancer. On multivariate logistic regression analysis, intraoperative unfavorable incidents were associated significantly only with prior open colorectal surgery (odds ratio, 2.8; P = .006) and laparoscopic major hepatectomy (odds ratio, 2.4; P = .009). CONCLUSION Laparoscopic minor hepatectomy can be performed safely in patients who have undergone previous open colorectal surgery. Laparoscopic major hepatectomy after open colorectal surgery may be challenging. Careful risk assessment in the decision-making process is required not to compromise patient safety and to guarantee the expected benefits from the minimally invasive approach.

Development and validation of a difficulty score to predict intraoperative complications during laparoscopic liver resection: Difficulty score to predict complications during laparoscopic liver resection

Previous studies have demonstrated that patient, surgical, tumour and operative variables affect the complexity of laparoscopic liver resections. However, current difficulty scoring systems address only tumour factors. The aim of this study was to develop and validate a predictive model for the risk of intraoperative complications during laparoscopic liver resections.