Short-term outcomes favor laparoscopic over open liver resection

Last Updated: 2015-12-16

By Will Boggs MD

NEW YORK (Reuters Health) - Laparoscopic liver resection (LLR) is associated with fewer complications and shorter hospital stay, with no increase in mortality, compared with open liver resection (OLR), according to a systematic review of more than 9,000 LLR cases and 2,900 OLR cases worldwide.

"Despite the lack of randomized trials, evidence now is strong enough to confirm the safety of laparoscopic approach to liver surgery in selected cases," Dr. Ruben Ciria from University Hospital Reina Sofia in Cordoba, Spain, told Reuters Health by email. "Furthermore, laparoscopic approach for nonanatomic wedge and left lateral resections is now considered standard practice in several centers."

LLR is emerging as a feasible approach for many patients, Dr. Ciria and colleagues note in Annals of Surgery, online November 27. But it is a technically demanding procedure and carries the risk of major hemorrhage from liver parenchyma or vascular structures that may be difficult to control laparoscopically. There are also concerns about its oncologic adequacy.

The team - from Japan, Spain, France and the U.S. - analyzed the world literature on LLR and compared the short-term outcomes of LLR versus OLR.

The annual number of LLR cases has trended upward since 2007, with more than 2,000 cases in 2013 and a significantly higher proportion being major LLR, the researchers write in their report.

Most of the 9,527 LLR cases were for malignancy (65%), but more than a third (35%) were for benign indications. The overall mortality rate was 0.39%, with 15 deaths attributed to bleeding, bile leak with sepsis, or liver failure.

A meta-analysis of 2,900 paired LLR and OLR cases, LLR was associated with significantly fewer overall complications, less estimated blood loss, fewer blood transfusions, and shorter hospital stay. In the most recent years, operative times have tended to be shorter with LLR.

A meta-analysis restricted to the major resection cases also favored LLR in the number of overall complications, estimated blood loss, and hospital stay.

Resection margins did not differ significantly between LLR and OLR overall or in the subgroup of patients who underwent major resection.

"Liver surgery has been the last field in general surgery with the incorporation of laparoscopic approach," Dr. Ciria said. "While it is very widespread in bariatric, colorectal, gastric, esophageal, and so on, LLR is really complex and thus, liver surgeons have been reluctant to use this approach. It was surprising to see the huge growth of laparoscopic liver resections in the last 5-6 years."

"The approach to laparoscopic liver procedures may only be performed in high-volume liver centers in which open surgery has been a routine in the last years," Dr. Ciria said. "Furthermore, liver resections must be discussed in a multidisciplinary basis with liver-specific oncologists, radiologists, hematologists and surgeons. Only high-volume centers with expert teams may offer the best approach for liver patients."

"Multicentric studies and proper trials should be performed in order to increase the strength in the potential recommendations regarding laparoscopic approach in liver diseases," Dr. Ciria added.

SOURCE: http://bit.ly/1YkkdM9

Ann Surg 2015.