Clinical

Laparoscopic and open resection equivalent for liver tumors

Last Updated: 2010-01-26 20:08:55 -0400 (Reuters Health)

By Karla Gale

NEW YORK (Reuters Health) - At high-volume centers with experienced surgeons, laparoscopic liver resection is as good as open resection and easier on the patients, according to a single-center study from Norway.

Most hepatobiliary centers only perform open surgery, partly because long-term oncologic outcomes are not well documented, Dr. Airazat M. Kazaryan, from Rikshospitalet University Hospital, Oslo, and co-authors note. Their report in the January Archives of Surgery describes 10 years of experience with laparoscopic hepatectomies at Rikshospitalet.

"Our major findings were good oncologic outcome and similar outcomes for anatomic and non-anatomic liver resections," Dr. Kazaryan told Reuters Health by email. "Advanced operative techniques and new sophisticated laparoscopic surgical equipment enabling a wide application of safe non-anatomic resections allowed us to offer a parenchyma-sparing resection to a majority of our patients."

Between 1998 and 2008, the surgeons performed 177 resections during 149 laparoscopic procedures in 139 patients, primarily for colorectal metastases. Median operative time was 164 minutes, and median blood loss was 350 mL. Tumors ranged in size from 0.5 to 13.5 cm, and surgical margins were clear in 140 of 149 malignant specimens. The rate of blood transfusion was 18%, and the median hospital stay was 3 days.

Five procedures (3.4%) were converted to open surgery and one to laparoscopic tumor ablation. One patient with severe comorbidity required conversion to open surgery because of bleeding from the hilar vessels and hepatic veins; this patient required a reoperation the following day and later died of multiorgan failure. Ten intraoperative complications (6.7%) occurred, including seven perforations of adherent or adjacent organs.

Eighteen procedures (12.6%) were associated with postoperative complications, mostly involving infections. There were three bile leaks (two were managed nonoperatively, but the third required three reoperations) and one umbilical hernia.

The research team notes that there were no cases of gas embolism, "which represented a major cause for anxiety during the early phase of laparoscopic liver surgery."

The median survival is 65 months, although the upper limit of the range has not been reached. The 5-year actuarial survival was 46% for patients with colorectal metastases.

"This corresponds to the best reported outcomes after open liver resection and is better than outcomes from our own reported experience with open surgery," the authors write. Even after major resections, the postoperative course was better, they note.

"We have felt a strong, growing and understandable press from well informed patients to perform laparoscopic operation instead of open," Dr. Kazaryan said. "If surgeons get necessary support from health care management, it will be possible to provide a minimally invasive laparoscopic treatment to more than half of patients requiring liver surgery."

The researchers emphasize that a major impediment to laparoscopic liver resection is the long learning curve.

Dr. Kazaryan expanded on this, commenting that "if a trainee working in a specialized hepatopancreatobiliary department has a considerable experience in laparoscopic surgery beforehand, it could take about 50 cases, which could be accumulated within 2-3 years."

Nevertheless, he added, "There is no doubt that our studies as well as the research in other centers practicing laparoscopic techniques will encourage more centers around the world to empower laparoscopic techniques in liver surgery."

Noting that theirs was a retrospective study, the authors conclude, "The time has come to prove the observed benefits of the laparoscopic approach by randomized prospective trials."

In an invited critique, Dr. Michel Gagner, from Florida International University in Miami Beach, comments that operative times in this review were satisfactory, and complication rates reasonable. Moreover, he said, "the myth of increased venous gas emboli from laparoscopy is shattered."

Arch Surg 2010;145:34-41.