Laparoscopic liver resection versus open liver resection for intrahepatic cholangiocarcinoma: 3-year outcomes of a cohort study with propensity score matching

IntroductionLaparoscopic liver resection(LLR) for intrahepatic cholangiocarcinoma is debatable due to technical challenges associated with major hepatectomy and lymph node dissection. This study aims to analyze the long-term outcomes with propensity score matching.MethodsPatients who underwent liver resection for intrahepatic cholangiocarcinoma from August 2004 to October 2015 were enrolled. Those who had combined hepatocellular-cholangiocarcinoma and palliative surgery were excluded. Medical records were reviewed for postoperative outcome, recurrence, and survival. The 3-year disease-free survival(DFS) and 3-year overall survival(OS) were set as the primary endpoint, and 3-year disease-specific survival, 1-year OS, 1-year DFS, operative outcome, and postoperative complications were secondary endpoints.ResultsA total of 91 patients were enrolled with 61 in the open group and 30 in the laparoscopic group. Propensity score matching included 24 patients in both groups. In total, the 3-year OS was 81.2% in the open group and 76.7% in the laparoscopic group(p = 0.621). For 3-year DFS, open was 42.5% and laparoscopic was 65.6%(p = 0.122). Mean operation time for the open group was 343.2 ± 106.0 min and laparoscopic group was 375.2 ± 204.0 min(p = 0.426). Hospital stay was significantly shorter in the laparoscopic group(9.8 ± 5.1 days) than the open group(18.3 ± 14.7, p=<0.001). There was no difference in complication rate and 30-day readmission rate. Tumor size, nodularity, and presence of perineural invasion showed an independent association with the 3-year DFS in multivariate analysis.ConclusionLaparoscopic liver resection for intrahepatic cholangiocarcinoma is technically feasible and safe, providing short-term benefits without increasing complications or affecting long-term survival.     

Postoperative outcomes after laparoscopic or open gastrectomy. A national cohort study of 10,343 patients

BackgroundLaparoscopy for gastric cancer has not been as popular compared with other digestive surgeries, with conflicting reports on outcomes. The aim of this study focuses on the surgical techniques comparing open and laparoscopy by assessing the morbi-mortality and long-term complications after gastrectomy.MethodsA retrospective study (2013–2018) was performed on a prospective national cohort (PMSI). All patients undergoing resection for gastric cancer with a partial gastrectomy (PG) or total gastrectomy (TG) were included. Overall morbidity at 90 post-operative days and long-term results were the main outcomes. The groups (open and laparoscopy) were compared using a propensity score and volume activity matching after stratification on resection type (TG or PG).ResultsA total of 10,343 patients were included. The overall 90-day mortality and morbidity were 7% and 45%, with reintervention required in 9.1%. High centre volume was associated with improved outcomes. There was no difference in population characteristics between groups after matching. An overall benefit for a laparoscopic approach after PG was found for morbidity (Open = 39.4% vs. Laparoscopy = 32.6%, p = 0.01), length of stay (Open = 14[10–21] vs. Laparoscopy = 11[8–17] days, p<0.0001). For TG, increased reintervention rate (Open = 10.8% vs. Laparoscopy = 14.5%, p = 0.04) and increased oesophageal stricture rate (HR = 2.54[1.67–3.85], p<0.001) were encountered after a laparoscopic approach. No benefit on mortality was found for laparoscopic approach in both type of resections after adjusted analysis.ConclusionsLaparoscopy is feasible for PG with a substantial benefit on morbidity and length of stay, however, laparoscopic TG should be performed with caution, with of higher rates of reintervention and oesophageal stricture.     

Intensity-modulated radiotherapy following null-margin resection is associated with improved survival in the treatment of intrahepatic cholangiocarcinoma

Background

The current study is the first to examine the effectiveness and toxicity of postoperative intensity-modulated radiotherapy (IMRT) in the treatment of intrahepatic cholangiocarcinoma (ICC) abutting the vasculature. Specifically, we aim to assess the role of IMRT in patients with ICC undergoing null-margin (no real resection margin) resection.

Methods

Thirty-eight patients with ICC adherent to major blood vessels were included in this retrospective study. Null-margin resection was performed on all patients; 14 patients were further treated with IMRT. The median radiation dose delivered was 56.8 Gy (range, 50-60 Gy). The primary endpoints were overall survival (OS) and disease-free survival (DFS).

Results

At a median follow-up of 24.6 months, the median OS and DFS of all patients (n=38) were 17.7 months (95% CI, 13.2-22.2) and 9.9 months (95% CI, 2.8-17.0), respectively. Median OS was 21.8 months (95% CI, 15.5-28.1) among the 14 patients in the postoperative IMRT group and 15.0 months (95% CI, 9.2-20.9) among the 24 patients in the surgery-only group (P=0.049). Median DFS was 12.5 months (95% CI, 6.8-18.2) in the postoperative IMRT group and 5.5 months (95% CI, 0.7-12.3) in the surgery-only group (P=0.081). IMRT was well-tolerated. Acute toxicity included one case of Grade 3 leukopenia; late toxicity included one case of asymptomatic duodenal ulcer discovered through endoscopy.

Conclusions

The study results suggest that postoperative IMRT is a safe and effective treatment option following null-margin resections of ICC. Larger prospective and randomized trials are necessary to establish postoperative IMRT as a standard practice for the treatment of ICC adherent to major hepatic vessels.     

腹腔镜与开腹肝门部胆管癌根治术疗效比较的Meta分析

目的:系统评价腹腔镜肝门部胆管癌根治术(laparoscopic radical resection for hilar cholangiocarcinoma, LRRHC)与开腹肝门部胆管癌根治术(open radical resection for hilar cholangiocarcinoma, ORRHC)两种手术方式的临床疗效。方法:以laparoscopy、laparoscopic、laparotomy、open surgery、bile duct neoplasms、hilar cholangiocarcinoma、腹腔镜手术、开腹手术、胆管癌、肝门部胆管癌为检索词,检索PubMed、Embase、the Cochrane Library、CBM、CNKI、VANFUN数据库。检索时间为1960年01月至2020年12月。根据Cochrane系统评价原则,由两名研究者独立筛选文献并提取数据,进行质量评价后使用Review Manager 5.3版进行统计分析。计量资料采用均数差(MD)及其95%可信区间(95%CI)表示,计数资料采用比值比(OR)及其95%CI表示。采...     

机器人手术系统、腹腔镜及开腹手术治疗宫颈癌的对比研究

目的 探讨机器人手术系统在宫颈癌手术中的安全性、可行性及其临床应用价值。方法 回顾性分析2010年3月至2014年2月在第二炮兵总医院行宫颈癌根治术治疗的75例ⅠA～ⅡA期宫颈癌患者的临床资料,其中机器人（RRH）组23例、腹腔镜（LRH）组15例和开腹（ARH）组37例。结果RRH组、LRH组及ARH组的出血量分别为（110.6±31.0）ml、（274.2±44.6）ml 和（1219.0±738.7）ml,输血量分别为（17±100）ml、（80±160）ml 和（1000±560）ml,手术并发症的发生率分别为8.6％（2/23）、20.0％（3/15）和48.6％（18/37）,术后胃肠道的恢复时间分别为（33.2±17.0）h、（51.0±10.8）h 和（63.7±7.9）h。RRH组与LRH组及ARH组比较,上述4项指标的差异均有统计学意义（P＜0.05）。 结论在宫颈癌根治术中,机器人手术系统较腹腔镜和传统开腹术出血少、术后胃肠道恢复时间短及手术并发症低,提示机器人手术在宫颈癌治疗方面更具安全性、可行性和一定临床价值。     

Laparoscopic versus open surgery for colon cancer: A meta-analysis of 5-year follow-up outcomes

BackgroundColon cancer is one of the most common malignant tumors of digestive tract with a rather high incidence rate. Currently, surgery is the only radical therapy for colon cancer, while Laparoscopic colectomy (LAC) has become another focus since studies reported LAC could improve the short-time outcomes and quick recovery of patients compared with open colectomy (OC). However, it's still unclear whether LAC can better improve patients' long-time survival than OC.ObjectiveWe aimed to perform a meta-analysis to answer whether the 5-year recurrence and survival rate after LAC are comparable to those reported after OC in patient with colon cancer.MethodsWe searched Cochrane Library, PubMed, Embase, CBM, VIP, and CNKI for relevant studies. The time searched was from the establishment time of the databases to September 15, 2011. At the same time, we searched Google, Medical Martix and Baidu for more studies as well as a hand-search. We limited the language to English and Chinese. Two reviewers independently screened articles to identify randomized controlled trials (RCTs) according to the inclusion and exclusion criteria and assessed the methodological quality of included trials, and then extracted data. Meta-analysis was performed using RevMan5.0.ResultsFive RCTs involving 2695 patients reported long-term outcomes based on 5-year data and were included in the analysis. No significant differences between LAC and OC were found in the overall mortality (RR = 0.94; 95% CI (0.82, 1.09); P = 0.23, I² = 21%), total recurrence rate (RR = 0.94; 95% CI (0.81, 1.10); P = 0.24, I² = 27%), 5-year tumor free survival rate (RR = 1.00, 95% CI (0.94, 1.06); P = 0.96, I² = 0%). and overall 5-year survival (RR = 1.02; 95% CI (0.97, 1.07); P = 0.55, I² = 0%).ConclusionsThis meta-analysis suggests that LAC was as effective and safe as OC for colon cancer.     

Trans-arterial embolisation therapies for unresectable intrahepatic cholangiocarcinoma: a systematic review

Background

Unresectable intrahepatic cholangiocarcinoma (ICC) portends a poor prognosis despite standard systemic treatments which confer minimal survival benefits and significant adverse effects. This study aimed to assess clinical outcomes, complications and prognostic factors of TAE therapies using chemotherapeutic agents or radiation.

Methods

A literature search and article acquisition was conducted on PubMed (MEDLINE), OVID (MEDLINE) and EBSCOhost (EMBASE). Original articles published after January 2000 on trans-arterial therapies for unresectable ICC were selected using strict eligibility criteria. Radiological response, overall survival, progression-free survival, safety profile, and prognostic factors for overall survival were assessed. Quality appraisal and data tabulation were performed using pre-determined forms. Results were synthesized by narrative review and quantitative analysis.

Results

Twenty articles were included (n=929 patients). Thirty three percent of patients presented with extrahepatic metastases. After treatment, the average rate of complete and partial radiological response was 10% and 22.2%, respectively. Overall median survival time was 12.4 months with a median 30-day mortality and 1-year survival rate of 0.6% and 53%, respectively. Acute treatment toxicity (within 30 days) was reported in 34.9% of patients, of which 64.3% were mild to moderate in severity. The most common clinical toxicities were abdominal pain, nausea and vomiting, and fatigue. Multiplicity, localization and vascularity of the tumor may predict worse overall survival.

Conclusions

Trans-arterial therapies are safe and effective treatment options which should be considered routinely for unresectable ICC. Consistent and standardized methodology and data collection is required to facilitate a meta-analysis. Randomized controlled trials will be valuable in the future.     

Impact of systemic inflammation on outcome following resection for intrahepatic cholangiocarcinoma

AIMS: To analyse the results and prognostic factors affecting disease-free and overall survival following potentially curative resection for intrahepatic cholangiocarcinoma (IHCC). METHODS: Patients undergoing resection for IHCC from January 1996 to December 2006 were included. Data analysed included demographics, clinical and histopathology data. RESULTS: Twenty-seven patients were identified with a median age of 57 (32-84) years. The 1-, 3- and 5-year overall and disease-free survival rates were 74%, 16% and 16%, and 44%, 15% and 15%, respectively. On univariate analysis, age <65 years, female gender, neutrophil to lymphocyte ratio (NLR) >or= 5, micro-vascular invasion and lymph node involvement were predictors of poorer overall survival. Multivariate analysis did not identify any independent predictors of overall survival. A NLR >or= 5 was the only adverse predictor of disease-free survival. The median disease-free survival of patients with NLR >or= 5 was 6 months compared to 18 months for those with NLR < 5. There was a significant association between patients with a NLR >or= 5 and larger tumour size, satellite lesions, micro-vascular invasion and lymph node involvement. CONCLUSION: Long-term outcome following resection of IHCC is poor. A pre-operative NLR >or= 5 was an adverse predictor of disease-free survival and was associated with an aggressive tumour biology profile.     

Laparoscopic versus open hepatectomy for intrahepatic cholangiocarcinoma: Systematic review and meta-analysis of propensity score-matched studies

ObjectiveTo compare the effects of laparoscopic hepatectomy (LH) versus open hepatectomy (OH) on the short-term and long-term outcomes of patients with intrahepatic cholangiocarcinoma (ICC) through a meta-analysis of studies using propensity score-matched cohorts.MethodsThe literature search was conducted in PubMed, Embase, and Cochrane Library databases until August 31, 2022. Meta-analysis of surgical (major morbidity, the length of hospital stay, 90-day postoperative mortality), oncological (R0 resection rate, lymph node dissection rate) and survival outcomes (1-, 3-, and 5-year overall survival and disease-free survival) was performed using a random effects model. Data were summarized as relative risks (RR), mean difference (MD) and hazard ratio (HR) with 95% confidence intervals (95% CI).ResultsSix case-matched studies with 1054 patients were included (LH 518; OH 536). Major morbidity was significantly lower (RR = 0.57, 95% CI = 0.37–0.88, P = 0.01) and the length of hospital stay was significantly shorter (MD = −2.44, 95% CI = −4.19 to −0.69, P = 0.006) in the LH group than in the OH group, but there was no significant difference in 90-day postoperative mortality between the 2 groups. There were no significant differences in R0 resection rate, lymph node dissection rate, 1-, 3-, and 5-year overall survival or disease-free survival between the LH and OH groups.ConclusionsLH has better surgical outcomes and comparable oncological outcomes and survival outcomes than does OH on ICC. Therefore, laparoscopy is at least not inferior to open surgery for intrahepatic cholangiocarcinoma.     

Long-term outcomes following minimally invasive and open esophagectomy in Finland: A population-based study

BackgroundStudies of long-term survival after minimally invasive and open esophagectomy are needed. The aim of this study was to compare long-term outcomes following minimally invasive and open esophagectomy for esophageal cancer at the population level.MethodsAll patients undergoing minimally invasive (n = 159) or open transthoracic (n = 431) esophagectomy for esophageal cancer in Finland between 2004 and 2014 were identified from nationwide registries. Propensity score matching was used to create groups of 150 minimally invasive and open esophagectomies with balanced baseline characteristics (sex, age, comorbidity, center volume, year of surgery, histology, stage (local or locally advanced), and neoadjuvant therapy). The primary outcome was 1-year survival after surgery. Secondary outcomes were the 3-year, 5-year, and 90-day survival.ResultsThe propensity matched 1-year survival rate was 85.3% after minimally invasive and 74.7% after open esophagectomy (adjusted HR 0.53, 95% CI 0.31–0.89; P = 0.0174). At 3 years, those were 68.7% and 55.6% (adjusted HR 0.62; 95% CI 0.43–0.91; P = 0.0144), respectively; at 5 years, survival rates were 61.8% and 51.9% (adjusted HR 0.68, 95% CI 0.47–0.97; P = 0.0347). The 30- and 90-day survival rates after minimally invasive and open surgery were 99.3% vs. 98.0% and 97.3% vs. 92.0%, respectively, without statistical significance.ConclusionsIn this population-based propensity matched study, minimally invasive esophagectomy was associated with improved long-term survival. Due to multiple confounding factors replication studies are needed.     

Robotic vs. open radical cystectomy in bladder cancer: A systematic review and meta-analysis

Aims

To evaluate the safety and efficacy of robot-assisted radical cystectomy (RARC) compared with open radical cystectomy (ORC) in the treatment of bladder cancer.

Methods

A systematic search of Medline, Embase databases and the Cochrane Library was performed to identify studies that compared RARC and ORC and were published up to December 2012. Outcomes of interest included demographic and clinical characteristics, perioperative, pathologic variables and complications.

Results

Although there was a significant difference in the operating time in favor of ORC (WMD: 70.69 min; p < 0.001), patients having RARC might benefit from significantly fewer total complications (OR: 0.54; p < 0.001), less blood loss (WMD: −599.03 ml; p < 0.001), shorter length of hospital stay (WMD: −4.56 d; p < 0.001), lower blood transfusion rate (OR: 0.13; p = 0.002), less transfusion needs (WMD: −2.14 units; p < 0.001), shorter time to regular diet (WMD: −1.57 d; p = 0.002), more lymph node yield (WMD: 2.18 n; p = 0.001) and fewer positive lymph node (OR: 0.64; p = 0.03). There was no significant difference between the RARC and ORC regarding positive surgical margins.

Conclusions

In early experience, our data suggest that RARC appears to be a safe, feasible and minimally invasive alternative to its open counterpart when performed by experienced surgeons in selected patients.     

Outcomes of vascular resection associated with curative intent hepatectomy for intrahepatic cholangiocarcinoma

Background and aimsWe aimed to investigate the impact of vascular resection (VR) on postoperative outcomes and survival of patients undergoing hepatectomy for intrahepatic cholangiocarcinoma (ICC).MethodsA retrospective analysis of a multi-institutional series of 270 patients with resected ICC was carried out. Patients were divided into three groups: portal vein VR (PVR), inferior vena cava VR (CVR) and no VR (NVR). Univariate and multivariate analysis were applied to define the impact of VR on postoperative outcomes and survival.ResultsThirty-one patients (11.5%) underwent VR: 15 (5.6%) to PVR and 16 (5.9%) to CVR. R0 resection rates were 73.6% in NVR, 73.3% of PVR and 68.8% in CVR. The postoperative mortality rate was increased in VR groups: 2.5% in NVR, 6.7% in PVR and 12.5% in CVR. The 5-years overall survival (OS) rates progressively decreased from 38.4% in NVR, to 30.1% in CVR and to 22.2% in PVR, p = 0.030. However, multivariable analysis did not confirm an association between VR and prognosis. The following prognostic factors were identified: size ≥50 mm, patterns of distribution of hepatic nodules (single, satellites or multifocal), lymph-node metastases (N1) and R1 resections. In the VR group the 5-years OS rate in patients without lymph-node metastases undergoing R0 resection (VRR0N0) was 44.4%, while in N1 patients undergoing R1 resection was 20% (p < 0.001).ConclusionVascular resection (PVR and CVR) is associated with higher operative risk, but seems to be justified by the good survival results, especially in patients without other negative prognostic factors (R0N0 resections).     

Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy vs. cytoreductive surgery alone for intrahepatic cholangiocarcinoma with peritoneal metastases: A retrospective cohort study

BackgroundCytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) has survival benefits in patients with intraperitoneal malignant lesions, but there is no study specific to intrahepatic cholangiocarcinoma (ICC).PurposeTo compare the prognosis of patients with advanced ICC undergoing CRS + HIPEC compared with CRS alone.MethodsThis study was a retrospective cohort study of patients with advanced ICC treated at the Shanghai Eastern Hepatobiliary Surgery Hospital between 01/2014 and 12/2018. The patients were divided into either CRS + HIPEC or CRS group based on the treatment they received. Overall survival (OS), complications, hospital stay, biochemical indicators, tumor markers, and number of HIPEC were examined.ResultsThere were 51 and 61 patients in the CRS + HIPEC and CRS groups, respectively. There were no differences between the groups regarding preoperative CA19-9 levels (421 ± 381 vs. 523 ± 543 U/mL, P = 0.208). The hospital stay was longer in the CRS + HIPEC group (22.2 ± 10.0 vs. 18.6 ± 7.6 days, P = 0.033). The occurrence of overall complications was similar in the two groups (37.2% vs. 34.4%, P = 0.756). The postoperative CA19-9 levels were lower in the CRS + HIPEC group compared with the CRS group (196 ± 320 vs. 337 ± 396 U/mL, P = 0.044). The median OS was longer in the CRS + HIPEC group than in the CRS group (25.53 vs. 11.17 months, P < 0.001). Compared with the CRS group, the CRS + HIPEC group showed a higher occurrence of leukopenia (7.8% vs. 0, P = 0.040) but a lower occurrence of total bilirubin elevation (15.7% vs. 37.7%, P = 0.032).ConclusionCRS + HIPEC could be a treatment option for patients with advanced ICC, with improved OS and similar complications and adverse events compared with CRS alone.     

Laparoscopic versus open colorectal resection for cancer: A meta-analysis of results of randomized controlled trials on recurrence

Aims

Laparoscopic resection for colorectal cancer remains controversial. This is because it is uncertain whether recurrence rates after laparoscopic-assisted surgery is comparable to those reported after open surgery. We performed a meta-analysis of the published literature in an attempt to answer this question.

Methods

Eligible articles were identified by searches of MEDLINE, EMBase and the Cochrane database. Prospective randomized clinical trials were eligible if they included patients with colorectal cancer treated by laparoscopic surgery versus open surgery and followed for recurrence.

Results

Ten trials with information on disease recurrence on 2474 patients were included. In the combined results, no statistically significant difference in the OR for overall recurrence between the laparoscopic surgery and open surgery group was found (OR 0.93, 95% CI 0.71–1.21, P = 0.58). Stratified by recurrence type, the combined results of the individual reports show no statistically significant difference for local recurrence (OR 0.80, 95% CI 0.50–1.29, P = 0.36), distant metastases (OR 0.90, 95% CI 0.62–1.29, P = 0.56) and port or wound-site recurrence (OR 1.04, 95% CI 0.18–6.03, P = 0.97) between the two surgical techniques.

Conclusion

This meta-analysis supports that the recurrence rates for patients with colorectal cancer treated by laparoscopic surgery do not differ from those for open surgery. Longer follow-up studies will further define outcomes, comparing the two techniques in the treatment of colorectal cancer.