Complementary Use of Resection and Radiofrequency Ablation for the Treatment of Colorectal Liver Metastases: An Analysis of 395 Patients

Background

Liver resection and radiofrequency ablation (RFA) are two surgical options in the treatment of patients with colorectal liver metastases (CLM). The aim of this study was to analyze patient characteristics and outcomes after resection and RFA for CLM from a single center.

Methods

Between 2000 and 2010, 395 patients with CLM undergoing RFA (n = 295), liver resection (n = 94) or both (n = 6) were identified from a prospective IRB-approved database. Demographic, clinical and survival data were analyzed using univariate and multivariate analyses.

Results

RFA patients had more comorbidities, number of liver tumors and a higher incidence of extrahepatic disease compared to the Resection patients. The 5-year overall actual survival was 17 % in the RFA, 58 % in the Resection group (p = 0.001). On multivariate analysis, multiple liver tumors, dominant lesion >3 cm, and CEA >10 ng/ml were independent predictors of overall survival. Patients were followed for a median of 20 ± 1 months. Liver and extrahepatic recurrences were seen in 69 %, and 29 % of the patients in the RFA, and 40 %, and 19 % of the patients in the Resection group, respectively.

Conclusions

In this large surgical series, we described the characteristics and oncologic outcomes of patients undergoing resection or RFA for CLM. By having both options available, we were able to surgically treat a large number of patients presenting with different degrees of liver tumor burden and co-morbidities, and also manage liver recurrences in follow-up.     

Bleeding and hemostasis in laparoscopic liver surgery

Background

Minimally invasive liver resection is gaining acceptance worldwide. However, the laparoscopic approach often is reserved for small segmental resections due to the fear of significant blood loss. The expansion of laparoscopic liver surgery will depend on the ability of expert surgeons and technological advances to address the management of bleeding and hemostasis with any new approach. The 4½- year experience of a single center performing totally laparoscopic liver resections is presented, with special reference to the techniques the authors have developed to limit blood loss.

Methods

Between 2003 and 2007, 80 patients underwent laparoscopic liver surgery for benign and malignant conditions including colorectal cancer metastases (n = 31), hepatocellular carcinoma (n = 6), neuroendocrine tumor (n = 3), cystic lesion (n = 10), adenoma (n = 8), and focal nodular hyperplasia (n = 7). Totally laparoscopic resections included sectionectomy (n = 27), hemihepatectomy (n = 10), and single/multiple segmentectomies (n = 21). Data for all resections were recorded and analyzed retrospectively to assess blood loss, hospital stay, and morbidity.

Results

The median operative time was 150 min, and the median blood loss was 120 ml, with significantly more blood loss for right-sided transections than for the left liver surgery (821 vs 147 ml; p = 0.012). Four (57%) of seven resections converted to open procedures because of bleeding. No deaths occurred, and only two patients required intraoperative blood transfusions. There were eight complications and one bile leak. The median length of hospital stay was 3 days.

Conclusions

The authors’ experience with 80 totally laparoscopic liver resections over a 4½-year period demonstrates that laparoscopic liver surgery is safe and effective in experienced hands for major resections. An intimate knowledge of the technology and techniques available for preventing and managing significant hemorrhage during laparoscopic liver resection is required for all surgeons performing laparoscopic liver surgery.     

The laparoscopic approach for radiofrequency ablation of hepatocellular carcinoma—indication, technique and results

Background

The therapeutic regimen for patients suffering of HCC in liver cirrhosis must pay attention to the underlying liver disease. Surgical resection is often limited by liver function and transplantation, as an optimal therapy for many early diagnosed HCC, by the availability of organs. Due to three prospective, randomized trials radiofrequency ablation (RFA) is the standard method of local ablation. RFA compared with resection for HCC in liver cirrhosis yields similar results concerning overall survival but a lower rate of complications. The laparoscopic approach may be advantageous concerning the major drawback of RFA which is still the rate of local failure as shown by a meta-analysis of local recurrences.

Method

Indication for RFA was HCC in liver cirrhosis either as a definite therapy or as a bridging procedure for transplantation if the expected waiting time exceeded 6 months. Laparoscopic ultrasound, standardized algorithm of laparoscopic RFA procedure, track ablation and a Trucut biopsy were performed. The postoperative follow-up was done according to institutional standards. Patient data and parameters of laparoscopic RFA were prospectively documented, analyzed and compared with the results of previously published series found in a Medline search.

Results

34 patients were treated by laparoscopic RFA. The average time of follow-up was 36.9?±?28.3 months. There was no procedure-related mortality or surgical complications. An upstaging of the tumor stage by laparoscopic ultrasound was achieved in 32 % of the patients. The overall survival of these patients was 44.7?±?6.9 months. The intrahepatic recurrence rate was 61.8 % based on the number of patients treated. The results have been analyzed and compared with six independent papers identified in a Medline search that report on the treatment of patients with HCC in a liver cirrhosis by laparoscopic RFA with a mean follow-up of 12 or more months.

Conclusions

Laparoscopic RFA is a feasible and reliable therapy for unresectable HCCs in patients with cirrhosis. The laparoscopic RFA combines the advantage of a minimally invasive procedure concerning liver dysfunction with the ability of an accurate intraoperative staging by laparoscopic ultrasound.     

Intraoperative adverse events during laparoscopic colorectal resection—better laparoscopic treatment but unchanged incidence. Lessons learnt from a Swiss multi-institutional analysis of 3,928 patients

Purpose

Intraoperative adverse events significantly influence morbidity and mortality of laparoscopic colorectal resections. Over an 11-year period, the changes of occurrence of such intraoperative adverse events were assessed in this study.

Methods

Analysis of 3,928 patients undergoing elective laparoscopic colorectal resection based on the prospective database of the Swiss Association of Laparoscopic and Thoracoscopic Surgery was performed.

Results

Overall, 377 intraoperative adverse events occurred in 329 patients (overall incidence of 8.4 %). Of 377 events, 163 (43 %) were surgical complications and 214 (57 %) were nonsurgical adverse events. Surgical complications were iatrogenic injury to solid organs (n?=?63; incidence of 1.6 %), bleeding (n?=?62; 1.6 %), lesion by puncture (n?=?25; 0.6 %), and intraoperative anastomotic leakage (n?=?13; 0.3 %). Of note, 11 % of intraoperative organ/puncture lesions requiring re-intervention were missed intraoperatively. Nonsurgical adverse events were problems with equipment (n?=?127; 3.2 %), anesthetic problems (n?=?30; 0.8 %), and various (n?=?57; 1.5 %). Over time, the rate of intraoperative adverse events decreased, but not significantly. Bleeding complications significantly decreased (p?=?0.015), and equipment problems increased (p?=?0.036). However, the rate of adverse events requiring conversion significantly decreased with time (p?<?0.001). Patients with an intraoperative adverse event had a significantly higher rate of postoperative local and general morbidity (41.2 and 32.9 % vs. 18.0 and 17.2 %, p?<?0.001 and p?<?0.001, respectively).

Conclusions

Intraoperative surgical complications and adverse events in laparoscopic colorectal resections did not change significantly over time and are associated with an increased postoperative morbidity.     

Prior Fundoplication Does not Improve Safety or Efficacy Outcomes of Radiofrequency Ablation: Results from the U.S. RFA Registry

Background

Ongoing gastroesophageal reflux may impair healing and re-epithelialization after radiofrequency ablation (RFA) of Barrett’s esophagus (BE). Because prior fundoplication may improve reflux control, our aim was to assess the relationship between prior fundoplication and the safety/efficacy of RFA.

Methods

We assessed the U.S. RFA Registry, a nationwide registry of BE patients receiving RFA at 148 institutions, to compare the safety and efficacy of ablation between those with prior fundoplication and those with medical management (proton pump inhibition).

Results

Among 5,537 patients receiving RFA, 301 (5.4 %) had prior fundoplication. Of fundoplication subjects, 1.0 % developed stricture and 1.0 % were hospitalized after RFA. Rates of stricture, bleeding, and hospitalization were not statistically different (p?=?ns) between patients with and without prior fundoplication. Complete eradication of intestinal metaplasia and complete eradication of dysplasia were achieved in 71 % and 87 % of fundoplication patients, and 73 % and 87 % of patients without fundoplication, respectively (p?=?ns for both). Patients with prior fundoplication needed similar numbers of RFA sessions for eradication compared with those without fundoplication.

Conclusions

Radiofrequency ablation, with or without prior fundoplication, is safe and effective in eradicating BE. Prior fundoplication was associated with similar adverse event and efficacy rates when compared with medical management.     

Feasibility of Laparoscopic Re-resection for Patients with Recurrent Hepatocellular Carcinoma

Background

Repeated resection via an open approach is an effective treatment for post-operative recurrent hepatocellular carcinoma (HCC). However, there are limited data on the application of laparoscopic approach for recurrent HCC in patients with prior liver resections. The aim of this study was to review our experience of laparoscopic re-resection in patients with postoperative tumor recurrence.

Materials and methods

A total of 11 patients received laparoscopic re-resections for postoperative tumor recurrence in our center. Data were reviewed for demographics, tumor characteristics, and perioperative outcomes. Case-match analysis with the open approach was performed in a 1:2 ratio.

Results

Six patients had their first liver resection carried out via the open approach and the remaining five patients received the laparoscopic approach. The recurrent tumor size was 20 mm (12–50 mm) and ten patients had a solitary recurrence. Two patients had laparoscopic left lateral sectionectomy and the remaining nine patients had sub-segmentectomies. There was no significant difference in patient characteristics, preoperative liver function, and tumor features between the laparoscopic and open groups. Perioperative blood loss was significantly reduced in the laparoscopic group (100 vs. 314 mL; p = 0.014) but the morbidity rate (18.2 vs. 4.5 %; p = 0.199) and length of hospitalization were comparable (6 vs. 5 days; p = 0.831). The 3-year overall survival rates for the laparoscopic and open groups were 60.0 and 89.3 %, respectively (p = 0.279).

Conclusion

Our study showed that laparoscopic re-resection for recurrent HCC was feasible with satisfactory postoperative and oncological outcomes, even in patients with previous major liver resections.     

Short-Term Outcomes of Ablation Therapy for Hepatic Tumors: Evidence from the 2006–2009 Nationwide Inpatient Sample

Background

Radiofrequency ablation (RFA) for the treatment of hepatic tumors has been increasingly used across the United States. Whether treatment-related morbidity has remained low with broader adoption is unclear. We conducted this study to describe in-hospital morbidity associated with RFA for hepatic tumors and to identify predictors of adverse events in a nationally representative database.

Methods

Using the 2006?C2009 Nationwide Inpatient Sample, we evaluated all patients aged ??40?years who underwent an elective RFA for primary or metastatic liver tumors (N?=?1298). Outcomes included in-hospital procedure-specific and postoperative complications. Multivariable logistic regression analyses were performed to identify patient and facility predictors of complications.

Results

Most patients underwent a percutaneous (39.9?%) or laparoscopic (22.0?%) procedure for metastatic liver tumors (57.5?%). Procedure-specific complications were frequent (18.2?%), with transfusion requirements (10.7?%), intraoperative bleeding (4.3?%), and hepatic failure (2.8?%) being the most common. Arrhythmias [adjusted odds ratio (AOR)?=?1.93 (1.23?C3.04)], coagulopathy [AOR?=?4.65 (2.95?C7.34)], and an open surgical approach [AOR?=?2.77 (1.75?C4.36)] were associated with an increased likelihood of procedure-specific complications, whereas hospital RFA volume ??16/year was associated with a reduced likelihood [AOR?=?0.59 (0.38?C0.91)]. Postoperative complications were also common (12.0?%), with arrhythmias, heart failure, coagulopathy, and open surgical approach acting as significant predictors.

Conclusions

In-hospital morbidity is common after RFA for hepatic tumors. While several patient factors are associated with more frequent procedure-specific complications, treatment at hospitals with an annual volume ??16 cases/year was associated with a 41?% reduction in the odds of procedure-specific complications.     

Preoperative patient counseling for diagnostic renal biopsy and complications with renal radiofrequency ablation

Purpose

To identify preoperative factors associated with surgical complications and successful diagnostic renal biopsy in both laparoscopic and percutaneous radiofrequency ablation (RFA) of renal masses in order to help aid in preoperative patient counseling for renal RFA.

Methods

We reviewed our Institutional Review Board approved database from November 2001 to January 2011, containing 335 tumors treated with either laparoscopic (LRFA) or percutaneous RFA (CTRFA). Preoperative patient demographics, tumor characteristics, and intraoperative surgical data were collected along with biopsy results and clinicopathologic outcomes.

Results

RFA was performed on 335 renal tumors (124 LRFA, 211 CTRFA). Non-diagnostic biopsy occurred in 18 (5.5%) tumors. Of the 317 procedures performed, 121 complications occurred in 103 (30.7%) procedures. Multivariate analysis only showed CTRFA (vs LRFA) to increase the likelihood of non-diagnostic biopsy (OR 5.1, 95% CI 1.2–22, p = 0.032). Increased tumor size (p = 0.007) and synchronous ablations (p = 0.019) increased the risk for major complications, while decreased surgeon experience (p = 0.003) and tumors close to the collecting system (p = 0.005) increased the risk of any complication.

Conclusions

Preoperative recommendations can be made to patients in the future. We suggest counseling patients that when undergoing RFA, percutaneous approach increases the risk of non-diagnostic biopsy, increased tumor size increases the risk of major complications, having more than 1 tumor ablated increases the risk of a major complication, and tumors close to the collecting system may increase the risk of complications.     

Influence of Nonclinical Factors on Choice of Therapy for Early Hepatocellular Carcinoma

Background

Initial therapy for early hepatocellular carcinoma (HCC) with well-compensated cirrhosis is controversial. While we previously reported on the effect of clinical factors and surgeon specialty on choice of therapy for early HCC, other nonclinical factors also may impact decision-making.

Methods

Surgeons who treat HCC were invited to complete a web-based survey that included ten case scenarios. Choice of therapy—liver transplantation (LT), liver resection (LR), or radiofrequency ablation (RFA)—was analyzed using regression models.

Results

There were 336 responses for analysis. Most respondents were in academic centers (86 %) that offered LT (71 %). The median number of patients annually evaluated for HCC was 30. Both practice type and HCC case volume were associated with choice of therapy, but these associations were not independent of surgeon specialty. LT surgeons who did not also perform RFA were less likely than those LT surgeons who did offer RFA to choose RFA over LT (relative risk ratios (RRR) 0.38, P < 0.001). Non-LT surgeons were more likely than LT surgeons who also offered RFA to choose RFA over LT (RRR 2.24, P < 0.001). Surgeons who worked at hospitals where LT was performed were much more likely to choose LT over LR and RFA even if they did not personally perform LT (RRR 1.27 and RRR 3.33, P < 0.001).

Conclusions

Surgeon- and institution-related factors impact choice of therapy for early HCC even after adjustment for differences in clinical presentation. These data suggest that choice of therapy for patients with early HCC varies across providers independent of case selection.     

Standardization of the Fully Stapled Laparoscopic Roux-en-Y Gastric Bypass for Obesity Reduces Early Immediate Postoperative Morbidity and Mortality: A Single Center Study on 2606 Patients

Background

Various techniques of laparoscopic Roux-en-Y gastric bypass have been described. We completely standardized this procedure to minimize its sometimes substantial morbidity and mortality. This study describes our experience with the standardized fully stapled laparoscopic Roux-en-Y gastric bypass (FS-LRYGB) and its influence on the 30-day morbidity and mortality.

Methods

We retrospectively analyzed 2,645 patients who underwent FS-LRYGB from May 2004 to August 2008. Operative time, hospital stay and readmission, re-operation, and 30-day morbidity/mortality rates were then calculated. The 30-day follow-up data were complete for 2,606 patients (98.5%).

Results

There were 539 male and 2,067 female patients. Mean age was 39.2 years (range 14–73), mean BMI 41.44 kg/m² (range, 23–75.5). The mean hospital stay was 3.35 days (range 2–71). Mean total operative time was 63 min (range 35–150). One patient died of pneumonia within 30 days of surgery (0.04%). One hundred and fifty one (5.8%) patients had postoperative complications as follows: gastrointestinal hemorrhage (n?=?89, 3.42%), intestinal obstruction (n?=?9, 0.35%), anastomotic leak (n?=?5, 0.19%) and others (n?=?47, 1.80%). In 66 patients, the bleeding resolved without any surgical re-intervention. One hemorrhage resulted in hypovolemic shock with subsequent renal and hepatic failure.

Conclusion

The systematic approach and the full standardization of the FS-LRYGB procedure contribute highly to the very low mortality and the low morbidity rates in our institution. Gastrointestinal bleeding appears to be the commonest complication, but is self-limiting in the majority of cases. Our approach also significantly reduces operative time and turns the technically demanding laparoscopic Roux-en-Y gastric bypass procedure into an easy reproducible operation, effective for training.     

Current status of laparoscopic liver surgery in Japan: results of a multicenter Japanese experience

Purpose

Laparoscopic liver surgery is widely performed around the world, and surgeons recognize its feasibility. We herein report the current status of laparoscopic liver surgery in Japan.

Methods

A questionnaire survey was conducted at 761 hospitals, including 41 member hospitals of the Japanese Endoscopic Liver Surgery Study Group and 720 facilities certified by the Japanese Society of Gastroenterological Surgery. Four hundred ninety-one hospitals responded to the questionnaire (response rate: 64 %). The data collected from 2,259 patients in 124 hospitals that reported performing laparoscopic liver resection were used. The surgical procedures and intraoperative complications, including the rate of conversion to open surgery, and morbidity rates were analyzed.

Results

Pure laparoscopic procedures were performed in 1,346 patients (59.6 %), hand-assisted procedures in 174 (7.7 %) and hybrid procedures in 739 (32.7 %). Laparoscopic hepatectomy was performed in 1,982 patients (87.7 %): hemihepatectomy in 141 (7.1 %), sectionectomy in 87 (4.4 %), left lateral sectionectomy in 208 (10.5 %), segmentectomy in 91 (4.6 %) and non-anatomical partial resection in 1,248 (63.0 %). A total of 45 procedures (2.3 %) were converted to conventional open surgery. Postoperative complications occurred in 91 patients (4.6 %).

Conclusions

Laparoscopic liver surgery is a safe, feasible procedure for treating liver disease in carefully selected patients.     

Laparoscopic resection for hepatocellular carcinoma: a matched-pair comparative study

Background

Only a few series have demonstrated the safety of laparoscopic resection for hepatocellular carcinoma (HCC) and the benefits of this approach. Moreover, these studies reported mostly minor and nonanatomic hepatic resections. This report describes the results of a pair-matched comparative study between open and laparoscopic liver resections for HCC in a series of essentially anatomic resections.

Methods

Patients were retrospectively matched in pairs for the following criteria: sex, age, American Society of Anesthesiology (ASA) score, severity of liver disease, tumor size, and type of resection. A total of 42 patients undergoing laparoscopy were compared with patients undergoing laparotomy during the same period. Surgeons from the authors’ department not trained in laparoscopy performed open resections. Operative, postoperative, and oncologic outcomes were compared.

Results

The mean duration of surgery was similar in the two groups. Significantly less bleeding was observed in the laparoscopic group (364.3 vs. 723.7 ml; p < 0.0001). Transfusion was required for four patients (9.5%) in the laparoscopic group and seven patients (16.7%) in the open surgery group (p = 0.51). Postoperative ascites was less frequent after laparoscopic resections (7.1 vs. 26.1%; p = 0.03). General morbidity was similar in the two groups (9.5 vs. 11.9%; p = 1.00). The mean hospital stay was significantly shorter for the patients undergoing laparoscopy (6.7 vs. 9.6 days; p < 0.0001). The surgical margin and local recurrence adjacent to the liver stump were not affected by laparoscopy. The overall postoperative survival rates in the laparoscopic group were 93.1% at 1 year, 74.4% at 3 years, and 59.5% at 5 years and, respectively, 81.8, 73, and 47.4% in the open surgery group (p = 0.25). The postoperative disease-free survival rates in the laparoscopic group were at 81.6% at 1 year, 60.9% at 3 years, and 45.6% at 5 years, respectively, 70.2, 54.3, and 37.2% in the open surgery group (p = 0.29).

Conclusions

Laparoscopic resection of HCC for selected patients gave a better postoperative outcome without oncologic consequences. Prospective trials are required to confirm these results.     

The minimally invasive approach is associated with reduced perioperative thromboembolic and bleeding complications for patients receiving preoperative chronic oral anticoagulant therapy who undergo colorectal surgery

Background

The data on the perioperative risk of both thromboembolism and hemorrhage for patients receiving chronic oral anticoagulation who undergo colorectal surgery are sparse. In addition, it is uncertain whether the use of the laparoscopic instead of open technique entails additional risk for these patients. This study aimed to evaluate surgical outcomes, with a particular focus on perioperative thromboembolic and bleeding complications for patients receiving chronic oral anticoagulation therapy who undergo open or laparoscopic colorectal resection.

Methods

Patients undergoing colorectal resection between 1994 and 2011 on preoperative chronic oral anticoagulant therapy were included in the study. Patient demographics, characteristics, and perioperative outcomes, with particular emphasis on thromboembolism and bleeding risks, were evaluated comparing laparoscopic and open colectomy.

Results

The study enrolled 261 patients receiving chronic anticoagulation therapy (102 laparoscopic colectomy vs 159 open colectomy patients). The patients had a mean age of 57.9 years and a mean body mass index (BMI) of 29.3 kg/m². The conversion rate was 8.8 % (n = 9) for laparoscopic operations. Laparoscopic and open cases had comparable BMIs and levels of preoperative hemoglobin. Anastomotic leak, postoperative hospital stay, and surgical-site infection rates were similar for the two groups. Although the laparoscopic group had a significantly greater mean age (p < 0.001) and American Society of Anesthesiology (ASA) score (p = 0.005), the rates for postoperative venous thromboembolism (24.5 vs 2.9 %; p < 0.001), urinary complications (6.9 vs 0 %; p = 0.008), and overall morbidity (44.7 vs 17.7 %; p < 0.001) were lower after laparoscopic surgery. Although the rates for intra- and postoperative blood transfusion were similar, the postoperative hemoglobin levels were significantly higher after laparoscopic surgery. One patient in the laparoscopic group died of sepsis on postoperative day 3.

Conclusion

For the patients receiving preoperative chronic anticoagulant therapy who underwent colorectal resection, the laparoscopic approach was associated with lower thromboembolic and hemorrhagic complications than open surgery.     

Aberrant left hepatic artery in laparoscopic antireflux procedures

Background

The aberrant left hepatic artery (ALHA) is an anatomic variation that may present an obstacle in laparoscopic antireflux procedures. Based on our experience, we addressed the following questions: How frequent is ALHA? When or why is it divided? What is the outcome in patients after division of the ALHA?

Methods

From a prospective collected database of 720 patients undergoing laparoscopic antireflux surgery, we collected the following information: presence of an ALHA, clinical data, diagnostic workup, operative reports, laboratory data, and follow-up data.

Results

In 57 patients (7.9%) (37 men and 20 women; mean age, 51 ± 15.7 years), an ALHA was reported. Hiatal dissection was impaired in 17 patients (29.8%), requiring division of the ALHA. In three patients (5.3%), the artery was injured during dissection; in one case (1.8%), it was divided because of ongoing bleeding. Ten of the divided ALHA (55.5%) were either of intermediate size or large. Mean operating time was 2.2 ± 0.8 h; mean blood loss was 63 ± 49 ml. Postoperative morbidity was 5.3% and mortality was 0%. None of the patients with divided hepatic arteries had postoperative symptoms related to impaired liver function. Postoperatively, two patients (11.7%) had transient elevated liver enzymes. At a mean follow-up of 28.5 ± 12.8 months, no specific complaints could be identified.

Conclusions

ALHA is not an uncommon finding in laparoscopic antireflux surgery and may be found in ≥8% of patients. Division may be required due to impaired view of the operating field or bleeding. Patients do not experience clinical complaints after division, but liver enzymes may be temporarily elevated.     

An audit of short- and long-term outcomes after laparoscopic removal of common bile duct stones in Finland

Background and aim

To audit short- and long-term outcomes after laparoscopic common bile duct exploration (LCBDE) and factors influencing the success of the laparoscopic treatment.

Methods

From January 1999 to December 2011, 288 patients (93 males) underwent a single-stage laparoscopic cholecystectomy combined with LCBDE in two Finnish Hospitals. Short-term outcome data were collected prospectively. Long-term outcomes were examined retrospectively. The main measures of outcome were the success of laparoscopic CBD stone clearance and recurrence of CBD stones in the long-term, with 30-day mortality, morbidity, and the length of postoperative hospital stay as secondary outcome measures.

Results

CBD stones were successfully removed by one-stage laparoscopic procedure in 232 of the 279 patients (83.2 %) with verified CBD stones and after conversion to open surgery in additional 28 patients (93.2 %). Nineteen patients (6.8 %) having residual stones after surgery were successfully treated with postoperative ERCP. On multivariate analysis, the independent factors associated with a failed laparoscopic stone clearance were stone size over 7 mm [OR 3.51 (95 % CI 1.53–8.03), p = 0.003], difficult anatomy [OR 18.01 (5.03–64.49), p < 0.001] and transcholedochal approach [OR 2.98 (1.37–4.47), p = 0.006]. Laparoscopic stone clearance also failed in all 11 patients having impacted stones at the ampulla of Vater. Cumulative long-term recurrence rate was 3.6 % at 5 years and 6.0 % at 10 years. Thirty-day mortality was 0.3 % and morbidity 12.2 %. Postoperative hospital stay was median 2 (IQR 1–3) days after transcystic CBD removal and 4 (IQR 3–7) days after transcholedochal CBD removal, p < 0.001.

Conclusion

Our results show that one-stage LC combined with LCBDE stone clearance is safe and effective in most patients thus reducing the number of additional, potentially dangerous endoscopic procedures. Moreover, large or impacted stones are a risk factor for failed stone clearance.     

Conventional Versus Laparoscopic Surgery for Hepatic Hydatidosis: a 6-Year Single-Center Experience

Background

The aim of this study is to evaluate the clinical results of laparoscopic surgery compared with conventional surgery.

Methods

Records of patients who underwent surgery for liver hydatid disease between 2005 and 2011 were reviewed. Operative time, blood loss, conversion to open, postoperative morbidity, mortality, hospital stay, and recurrence rate were measured.

Results

Among 353 eligible patients, 60 were considered for laparoscopic and 293 for conventional surgery. Operative time was slightly increased in laparoscopic group. No major blood loss and blood transfusion were needed. Postoperative hospital stay was significantly short in laparoscopic group (3.8?±?1.2 days) than that in conventional group (7.4?±?1.4 days). The overall morbidity was 13.3 % (8/60) in laparoscopic and 19.8 % (58/293) in conventional group without significance. Both conversion rate and mortality was 0 %. One recurrence in laparoscopic (1.7 %, 1/60) and five in conventional group (1.7 %, 5/293) occurred within 48 months of follow-up.

Conclusions

Laparoscopic treatment of liver hydatid disease is safe and effective in selected patients with all its advantages.     

Intraoperative Ablation for Small HCC not Amenable for Percutaneous Radiofrequency Ablation in Child A Cirrhotic Patients

Background

Radiofrequency ablation (RFA) was initially started by radiologists as a percutaneous treatment, but surgeons started to use RFA by surgical approach for patients with tumors at locations difficult for the percutaneous procedure. The aim was to evaluate the results of intraoperative RFA for small hepatocellular carcinomas (HCCs) (<3 cm) in locations difficult for a percutaneous approach.

Methods

Two hundred forty-seven patients with small solitary HCC (<3 cm) were treated; 196 via percutaneous RFA while 51 patients presented at sites not amenable for percutaneous route. Twenty-seven out of 51 patients underwent surgical resection, while 24/51 patients underwent intraoperative RFA.

Results

The location and depth of the tumor from the liver capsule was the only significant factors in the choice of the surgeon between resection and RFA. RFA was successful in all tumors (complete ablation rate of 100 %). In the surgery group, all patients achieved R0 resection. Complication rate was comparable (p?=?1.0). After a median follow-up of 37 months (range, 10–45 months), no tumors showed neither local progression nor local recurrence and no significant difference was observed between two groups as regards early recurrence and number of de novo lesions (p?=?0.49). One-year and 3-year survival rates were 93 % and 81 %, respectively, in the resection group comparable to the corresponding rates of 92 % and 74 % in the RFA group (p?=?0.9).

Conclusion

For small HCC in locations difficult for a percutaneous approach, intraoperative RFA can be an alternative option for deep-seated tumors necessitating more than one segmentectomy achieving similar tumor control, and overall and disease-free survival.     

Minimally invasive surgery versus percutaneous radio frequency ablation for the treatment of single small (≤3 cm) hepatocellular carcinoma: a case–control study

Background

Patients with single small hepatocellular carcinoma (HCC) can be managed by surgical resection or radio frequency ablation (RFA), with similar recurrence and survival rates. Recently, minimally invasive surgery (MIS) has been introduced in liver surgery, and the advantage/drawback balance between surgery and RFA needs reassessment.

Methods

Patients with Child-Pugh class A or B cirrhosis, and with single 1–3 cm HCC, undergoing MIS (laparoscopic or robot-assisted) or RFA from July 1998 to December 2012 were compared.

Results

Overall, 45 patients underwent MIS, and 60 underwent RFA. Groups were not statistically different regarding type of underlying liver disease, HCC size, and AFP. However, RFA patients showed worse liver synthetic function with lower albumin and higher bilirubin serum levels, and higher ASA scores. Patients with HCC in segments 2–6 were more often treated by MIS. The incidence of complications was similar between groups (RFA: 6/60, 10 % vs. MIS: 5/45, 11 %, p = 0.854), and there was no measurable difference in the rate of procedure-related blood transfusions (RFA: 1/60, 1.7 % vs. MIS: 3/45, 6.7 %, p = 0.185). Local recurrence was only detected after RFA (11.7 %, p = 0.056, log-rank). Overall survival was higher in the MIS group (p = 0.042), with median survivals of 100 ± 13.5 versus 68 ± 15.9 months.

Conclusion

The present data need further validation. Selected patients with single ≤3-cm HCCs can be safely treated by MIS, without increased risk of perioperative complication, and with a lower risk of local recurrence. MIS should be especially favoured in patients with peripheral HCCs in segments 2–6, and/or when a histological assessment is desirable.

     

Laparoscopic resection of paraaortic or paracaval lesions: feasibility and outcome

Background

Laparoscopic retroperitoneal lymph node dissection of paraaortic and paracaval lymph nodes is used to stage nonseminomatous germ cell tumors. Primary tumors can arise from the retroperitoneum, and tumors from nonurologic malignancy also may metastasize to retroperitoneal lymph nodes. This study aimed to describe the authors’ experience with laparoscopic resection of these lesions.

Methods

A consecutive series of patients between January 2007 and June 2011 with paraaortic, aortocaval, or paracaval tumors with a maximum diameter smaller than 10 cm and confined to the abdomen were considered for laparoscopic resection. Data were collected on size and pathology of the lesions, anesthesia time, postoperative stay, and postoperative morbidity and mortality.

Results

In this study, 25 patients with a median age of 49 years were assessed for laparoscopic resection. Eight patients were considered unsuitable for a laparoscopic approach because of tumor location (n = 5), previous retroperitoneal surgery (n = 1), stoma (n = 1), or lesion not clearly visible on computed tomography (n = 1). Of the 17 patients undergoing laparoscopic resection, 1 was found to have diffuse peritoneal disease at laparoscopy, whereas another was converted to an open procedure due to bleeding. All the laparoscopic patients had an R0 resection. The median hospital stay was significantly shorter in the laparoscopic group (2 days) than in the open group (6 days) (P = 0.009). One patient in the laparoscopic group with a functioning paraganglioma and advanced cardiac disease died on postoperative day 7.

Conclusion

Laparoscopic paraaortic and paracaval surgery for primary and recurrent tumors of the retroperitoneum is feasible, with clear resection margin rates similar to that observed for open surgery.     

Endoscopic versus Open Radiofrequency Ablation for Treatment of Small Hepatocellular Carcinoma

Background

Surgical radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) is associated with superior oncological outcome in comparison with percutaneous RFA. The present study aimed to retrospectively evaluate the relative perioperative safety and postoperative outcome of the laparoscopic or thoracoscopic approach versus the open approach to RFA for small HCC.

Methods

A retrospective analysis was performed in 55 consecutive patients who underwent open (n = 32) or laparoscopic/thoracoscopic (LTS) RFA (n = 23) for primary unresectable HCC between January 2005 and December 2010. Baseline characteristics, survival/recurrence rates, and complications after treatment were compared between the two groups.

Results

There was a trend showing that LTS RFA was performed for tumors located in the anterior segment (e.g., segments III, V, VIII). The LTS RFA group had a significantly lower intraoperative blood loss, shorter operative time, and shorter postoperative hospital stay, compared with the open RFA group. No major postoperative complications occurred in patients who underwent LTS RFA. No significant differences in overall survival, recurrence-free survival and local recurrence rates were observed between the two groups.

Conclusions

In consideration of operative invasiveness and postoperative recovery, LTS RFA is superior to the open approach in patients with small HCC. Moreover, the surgical outcome did not differ between the two approaches. Laparoscopic/thorascopic RFA can be considered to be a useful procedure for ablation therapy.