Neil W. Pearce

Short- and long-term outcomes after laparoscopic and open hepatic resection: systematic review and meta-analysis

BACKGROUND Laparoscopic liver resection (LLR) is now considered a feasible alternative to open liver resection (OLR) in selected patients. Nevertheless studies comparing LLR and OLR are few and concerns remain about long-term oncological equivalence. The present study compares outcomes with LLR vs. OLR using meta-analytical methods. METHODS Electronic literature searches were conducted to identify studies comparing LLR and OLR. Short-term outcomes evaluated included operating time, blood loss, length of hospital stay, peri-operative morbidity and resection margin status. Longer-term outcomes included local and distant recurrence, and overall (OS) and disease-free survival (DFS). Meta-analyses were performed using the Mantel-Haenszel method and Cohens d method, with results expressed as odds ratio (OR) or standardized mean difference (SMD), respectively, with 95% confidence intervals (CI). RESULTS Twenty-six studies met the inclusion criteria with a population of 1678 patients. LLR resulted in longer operating time, but reduced blood loss, portal clamp time, overall and liver-specific complications, ileus and length of stay. No difference was found between LLR and OLR for oncological outcomes. DISCUSSION LLR has short-term advantages and seemingly equivalent long-term outcomes and can be considered a feasible alternative to open surgery in experienced hands.

Laparoscopic versus open left lateral hepatic sectionectomy: A comparative study

BACKGROUND Laparoscopic liver surgery has been difficult to popularize. High volume liver centres have identified left lateral sectionectomy (LLS) as a procedure with potential for transformation into a primarily laparoscopic procedure where surgeons can safely gain proficiency. METHODS Forty-four patients underwent either laparoscopic (LLLS) or open (OLLS) left lateral sectionectomy (of segments II/III) for focal lesions at Southampton General Hospital. RESULTS OLLS and LLLS groups were matched for age, sex and tumour types resected. Median operative time in the LLLS group was 180 (40-340) min and 155 (110-330) min in the OLLS group (p=0.885) with median intra-operative blood loss in the LLLS group 80 (25-800) ml versus a larger 470 (100-3000) ml; p=0.002 for patients receiving OLLS. Post-operative stay was also shorter in the LLLS group (3.5 (1-6) days) compared to the OLLS group (7 (3-12) days; p<0.001). Resection margin was not different in the two groups (11 (1.5-30) mm (LLLS) versus 12 (4-40) mm (OLLS); p=1) and neither was the complication rate (13% for LLLS versus 25% for OLLS; p=0.541). There were no conversions to open in the LLLS group and no deaths in either group at 90 days. Between the first and second 12 LLLS the median operative time fell from 240 (70-340) min to 120 (40-120) min; p=0.005 as well as median post-operative hospital stay from 4.5 (2-6) days to 2 (1-4) days, p=0.001. CONCLUSION LLLS is a viable alternative to OLLS with potential improvements in intra-operative blood loss and shorter hospital stay without adversely affecting successful resection or complication rates. Larger prospective studies are required to explore this new avenue in laparoscopic liver surgery.

Short‐ and medium‐term results of totally laparoscopic resection for colorectal liver metastases

Laparoscopic surgery for primary colorectal cancer is now commonplace but the uptake of laparoscopic surgery for colorectal liver metastasis (CRLM) has been slow, mainly owing to doubts regarding safety, feasibility and oncological efficiency.

Laparoscopic right hepatectomy: a challenging, but feasible, safe and efficient procedure

BACKGROUND Few centers are undertaking major laparoscopic liver resections, because of the well-recognized technical difficulties and lack of training opportunities. METHODS The authors describe their technique for laparoscopic right hepatectomy, highlighting relevant details for accomplishing a safe and efficient procedure. Patients were chronologically divided into 2 groups to evaluate the impact of increasing experience on the surgical outcomes. RESULTS Group I included 17 patients and group II 18 patients. The conversion rate to open or hybrid techniques significantly decreased from 36% in group I to 6% in group II (P = .03). The hospital stay decreased from a median of 6 days in group I to a median of 4 days in group II (P = .05). Complications occurred in 4 patients (11%), of whom 3 were in group I. The mortality was zero. CONCLUSIONS Laparoscopic right hepatectomy is a safe and efficient procedure when performed at specialized centers with extensive experience in hepatic surgery. Long-term training is necessary to acquire adequate expertise.

Laparoscopic Left Lateral Liver Sectionectomy: A Safe, Efficient, Reproducible Technique

Background: Laparoscopic left lateral sectionectomy (LLLS) is procedure with potential for future transformation into a primarily laparoscopic procedure where surgeons can safely develop laparoscopic experience and gain proficiency. Methods: Between August 2004 and December 2007, 80 patients underwent laparoscopic liver resections in our unit, 30 of these were left lateral sectionectomies. The indications for surgery were both oncological and non-oncological. Results: 30 LLLS were performed. Median operative time and median postoperative hospital stay group were 180 (40–340) min and 4 (1–6) days, respectively, and were noted to fall significantly between the first (15 patients) and second parts of this series. The median free resection margin was 11 (1.5–30) mm and median perioperative blood loss was 80 (25–800) ml. Two minor complications were observed with no mortality and no conversions to open. Conclusion: LLLS is a feasible, safe and efficient procedure, associated with a quick, smooth learning curve. We report our technique illustrating methods and particulars which would be of great help to surgeons developing new laparoscopic liver services.

Hepatic splenosis mimicking HCC in a patient with hepatitis C liver cirrhosis and mildly raised alpha feto protein; the important role of explorative laparoscopy

BackgroundSplenosis is a heterotropic implantation of splenic fragments onto exposed vascularised peritoneal and intrathoracic surfaces, following splenic injury or elective splenectomy.Case presentationA 60 year old cirrhotic patient was referred to us with a hepatic mass, suspected to be HCC in a cirrhotic liver. A computerized tomography scan (CT) demonstrated a cirrhotic liver with a 2 × 2.7 cm focal hypervascular nodule, lying peripherally at the junction of segment 7 and 8. Diagnostic laparoscopy demonstrated a 3 cm exofitic dark brown splenunculus attached to the diaphragm and indenting the surface of segment 7 of the liver. The lesion was easily resected laparoscopically and shaved from the live surface with no need for a liver resection. The histopathological assessment confirmed the diagnosis of splenunculus, with no evidence of neoplasia.ConclusionHepatic splenosis is not a rare event and should be suspected in patients with a history of splenic trauma or splenectomy. Correct diagnosis is essential and will determine subsequent management plans. In doubtful cases laparoscopic investigation can offere essential information and should be part of the standard protocol for investigating suspected splenosis.

Laparoscopic versus open left lateral hepatectomy

Laparoscopic liver surgery is becoming more popular, and many high-volume liver centers are now gaining expertise in this area. Laparoscopic left lateral hepatectomy (LLLH) is a standardized and anatomically well-defined resection and may transform into a primarily laparoscopic procedure for cancer surgery or living donor hepatectomy for transplantation. Five case–control series were identified comparing a total of 167 cases (86 cases of LLLH plus 81 cases of open left lateral hepatectomy). Groups were matched by age and sex, with broadly similar indications for surgery and resection techniques. LLLH is associated with shorter hospital stays and less blood loss without compromising the margin status or increasing complication rates. Donors of LLLH grafts did not have higher graft-related morbidity. Prospective studies are required to define the safety in terms of disease-free and overall survival in this new avenue in laparoscopic liver surgery.

A Comparative Analysis of Safety and Efficacy of Different Methods of Tube Placement for Enteral Feeding Following Major Pancreatic Resection. A Non-Randomized Study

CONTEXT Postoperative enteral nutrition is thought to reduce complications and speed recovery after pancreatic resection. There is little evidence on the best route for delivery of enteral nutrition. Currently we use percutaneous transperitoneal jejunostomy or percutaneous transperitoneal gastrojejunostomy, or the nasojejunal route to deliver enteral nutrition, according to surgeon preference. OBJECTIVE To compare morbidity, efficiency, and safety of these three routes for enteral nutrition following pancreaticoduodenectomy. PATIENTS Data were obtained from a prospectively maintained database, for all patients undergoing pancreatic resection between January 2007 and June 2008. One-hundred pancreatic resected patients underwent enteral nutrition: 93 had Whipples operations and 7 had total pancreatectomies. INTERVENTION Enteral nutrition was delivered by agreed protocol, starting within 24 h of operation and increasing over 2-3 days to meet full nutritional requirement. RESULTS Delivery route of enteral nutrition was: percutaneous transperitoneal jejunostomy in 25 (25%), percutaneous transperitoneal gastrojejunostomy in 32 (32%) and nasojejunal in 43 (43%). The incidence of catheter-related complications was higher in percutaneous techniques: 24% in percutaneous transperitoneal jejunostomy and 34% in percutaneous transperitoneal gastrojejunostomy as compared to nasojejunal technique (12%). Median time to complete establishment of oral intake was 14, 14 and 10 days in percutaneous transperitoneal jejunostomy, percutaneous transperitoneal gastrojejunostomy, and nasojejunal groups, respectively. Nasojejunal tubes were removed at median 11 days (mean 11.5 days) compared to 5-6 weeks for percutaneous transperitoneal jejunostomy and percutaneous transperitoneal gastrojejunostomy. Commonest catheter-related complication in the percutaneous transperitoneal jejunostomy and percutaneous transperitoneal gastrojejunostomy was blockage (n=6; 10.5%), followed by pain after removal of feeding tube at 5-6 weeks (n=5; 8.8%), whereas in the nasojejunal group it was blockage (n=3; 7.0%), followed by displacement (n=2; 4.7%). Two patients died postoperatively in this cohort, however, there were no catheter-related mortalities. CONCLUSION Enteral nutrition following pancreatic resection can be delivered in different ways. Nasojejunal feeding was associated with fewest and less serious complications. On current evidence surgeon preference is a reasonable way to decide enteral nutrition but a randomized controlled trial is needed to address this issue.

Propensity score-based analysis of outcomes of laparoscopic versus open liver resection for colorectal metastases.

There is a need for high‐level evidence regarding the added value of laparoscopic (LLR) compared with open (OLR) liver resection. The aim of this study was to compare the surgical and oncological outcomes of patients with colorectal liver metastases (CRLM) undergoing LLR and OLR using propensity score matching to minimize bias.

Surgical management of benign and indeterminate hepatic lesions in the era of laparoscopic liver surgery

Background/Aims: The expansion of the laparoscopic approach for the management of benign liver lesions has raised concerns regarding the risk of widening surgical indications and compromising safety. Large single-centre series focusing on laparoscopic management of benign liver lesions are sporadic. Methods: We reviewed a prospectively collected database of patients undergoing pure laparoscopic liver resection (LLR) for benign liver lesions. All cases were individually discussed at a multidisciplinary team meeting. Results: Forty-six patients underwent 50 LLRs for benign disease. Indications for surgery were: symptomatic lesions, preoperative diagnosis of adenoma or cystadenoma, and lesions with an indeterminate diagnosis. The preoperative diagnosis was uncertain in 11 cases. Of these, histological diagnosis was hepatocellular carcinoma in one (9%) and benign lesion in 10 patients (91%). Thirteen patients (28%) required major hepatectomy. Three patients (7%) developed postoperative complications. Mortality was nil. The median postoperative hospital stay following major and minor hepatectomy was 4 and 3 days, respectively. Conclusion: The laparoscopic approach represents a safe option for the management of benign and indeterminate liver lesions, even when major hepatectomy is required. LLR should be only performed in specialized centres to ensure safety and strict adherence to orthodox surgical indication.