Laparoscopic versus open resection for rectal cancer: An individual patient data meta analysis of randomized controlled trials

Background and aimsThe role of laparoscopic rectal cancer resection remains controversial. Thus, we aimed to conduct a one-stage meta-analysis with reconstructed patient-level data using randomized trial data to compare long-term oncologic efficacy of laparoscopic and open surgical resection for rectal cancer.MethodsMedline, EMBASE and Scopus were searched for articles comparing laparoscopic with open surgery for rectal cancer. Primary outcome was disease free survival (DFS) while secondary outcome was overall survival (OS). One-stage meta-analysis was conducted using patient-level survival data reconstructed from Kaplan-Meier curves with Web Plot Digitizer. Shared-frailty and stratified Cox models were fitted to compare survival endpoints.ResultsSeven randomized trials involving 1767 laparoscopic and 1293 open resections for rectal cancer were included. There were no significant differences between both groups for DFS and OS with respective hazard ratio estimates of 0.91 (95% CI: 0.78–1.06, p = 0.241) and 0.86 (95% CI:0.73–1.02, p = 0.090). Sensitivity analysis for non-metastatic patients and patients with mid and lower rectal cancer showed no significant differences in OS and DFS between both surgical approaches. In the laparoscopic arm, improved DFS was noted for stage II (HR: 0.73, 95% CI:0.54–0.98, p = 0.036) and stage III rectal cancers (HR: 0.74, 95% CI:0.55–0.99, p = 0.041).ConclusionsThis meta-analysis concludes that laparoscopic rectal cancer resection does not compromise long-term oncologic outcomes compared with open surgery with potential survival benefits for a minimal access approach in patients with stage II and III rectal cancer.     

Comparison of three-year oncological results after restorative low anterior resection,non-restorative low anterior resection and abdominoperineal resection for rectal cancer

IntroductionOncological outcome might be influenced by the type of resection in total mesorectal excision (TME) for rectal cancer. The aim was to see if non-restorative LAR would have worse oncological outcome. A comparison was made between non-restorative low anterior resection (NRLAR), restorative low anterior resection (RLAR) and abdominoperineal resection (APR).Materials and methodsThis retrospective cohort included data from patients undergoing TME for rectal cancer between 2015 and 2017 in eleven Dutch hospitals. A comparison was made for each different type of procedure (APR, NRLAR or RLAR). Primary outcome was 3-year overall survival (OS). Secondary outcomes included 3-year disease-free survival (DFS) and 3-year local recurrence (LR) rate.ResultsOf 998 patients 363 underwent APR, 132 NRLAR and 503 RLAR. Three-year OS was worse after NRLAR (78.2%) compared to APR (86.3%) and RLAR (92.2%, p < 0.001). This was confirmed in a multivariable Cox regression analysis (HR 1.85 (1.07, 3.19), p = 0.03). The 3-year DFS was also worse after NRLAR (60.3%), compared to APR (70.5%) and RLAR (80.1%, p < 0.001), HR 2.05 (1.42, 2.97), p < 0.001. The LR rate was 14.6% after NRLAR, 5.2% after APR and 4.8% after RLAR (p = 0.005), HR 3.22 (1.61, 6.47), p < 0.001.ConclusionNRLAR might be associated with worse 3-year OS, DFS and LR rate compared to RLAR and APR.     

Is laparoscopic liver resection safe for intrahepatic cholangiocarcinoma? A meta-analysis

BackgroundThe use of laparoscopic liver resection for curative surgery of intrahepatic cholangiocarcinoma (ICC) is not well established. Herein, we perform a meta-analysis to compare the differences between laparoscopic liver resection (LLR) and open liver resection (OLR) for ICC.MethodsMultiple electronic databases were searched and 8 relevant studies containing 552 patients treated by LLR and 2320 treated by OLR were identified. The fixed effects and a random-effects model were used to perform a meta-analysis.ResultsCompared with OLR, LLR for ICC was associated with less blood transfusion (7.14% versus 17.11%; OR: 0.32; 95% CI 0.15 to 0.71; P < 0.05), higher R0 resection (85.63% versus 74.69%; OR: 1.48; 95% CI 1.13 to 1.95; P < 0.05), shorter length of stay (LOS) (SMD: −0.40; 95% CI -0.80 to 0.00; P = 0.05), less overall morbidities (20% versus 32.69%; OR: 0.50; 95% CI 0.33 to 0.78; P < 0.05), and less death due to tumor recurrence (22.39% versus 35.48%; OR: 0.50; 95% CI 0.29 to 0.86; P <0.05); but LLR was associated with smaller ICC, fewer major hepatectomies, less lymph node (LN) dissection rate, and inferior 5-year overall survival (OS) (P < 0.05). Duration of operation, blood loss, average LN retrieved, LN metastasis, major morbidities, mortality, tumor recurrence, 3-year OS and disease free survival (DFS), and 5-year DFS were comparable (P >0.05).ConclusionLLR for ICC is in the initial phase of exploration. More evidence is necessary to validate LLR for ICC.     

Trans-arterial chemoembolization + radiofrequency ablation versus surgical resection in hepatocellular carcinoma – A meta-analysis

BackgroundHepatocellular Carcinoma (HCC) remains the third most common cause of cancer death worldwide, with countries in Asia being affected the most. The mainstay of curative therapy for early HCC is radiofrequency ablation (RFA) or surgery; either surgical resection (SR) or liver transplantation. Latest evidence however suggests that combination of TACE+ RFA may provide outcomes comparable to SR.AimTo compare oncologic outcomes and safety profile of TACE + RFA to SR alone in HCC.Materials and methodsA systematic review was conducted through Pubmed, EMBASE and Cochrane Library for literature published before April 2019. Outcomes measured were disease-free survival(DFS), overall survival(OS) and major complications. DFS was further divided into local tumour progression(LTP), intrahepatic distant recurrence(IDR) and distant metastasis(DM).ResultsEight retrospective studies and one randomized controlled trial, involving 1892 patients met eligibility criteria and were included. Unadjusted pooled analysis demonstrated no significant difference in 1-year, 3-year and 5-year OS and 1-year DFS between TACE+RFA and SR. SR had superior 3-year DFS (OR 0.78, 95% CI 0.62–0.98, p = 0.03) and 5-year DFS (OR 0.74, 95% CI 0.58–0.95, p = 0.02) compared to TACE+RFA. When analysing only the propensity matched data, the difference in 3-year DFS and 5-year DFS was not significant. TACE+RFA had a higher LTP rate (OR 2.48, 95% CI 1.05–5.86, p = 0.04) compared to SR but IDR and DM rates were not significant.Discussion and conclusionTACE+RFA offer comparable oncologic outcomes in patients with HCC as compared with SR and with added benefit of lower morbidity.     

Predictors of recurrence following laparoscopic minor hepatectomy for hepatocellular carcinoma in the UK

AimsMinor hepatectomy, which is increasingly carried out laparoscopically (LLR), is a cornerstone of curative treatment for hepatocellular carcinoma (HCC). The majority of relevant publications however originate from regions with endemic viral hepatitis. Although the incidence of HCC in the UK is increasing, little is known about outcomes following LLR.MethodsConsecutive patients undergoing minor (involving ≤2 segments) LLR or open resection (OLR) at our institute between 2014 and 2021 were compared. Selection from a plethora of factors potentially impacting on overall (OS) and disease free survival (DFS) was optimised with Lasso regression. To enable analysis of patients having repeat resection, multivariate frailty modelling was utilised to calculate hazard ratios (HR).ResultsThe analysis of 111 liver resections included 55 LLR and 56 OLR. LLR was associated with a shorter hospital stay (5 ± 2 vs. 7 ± 2 days; p < 0.001) and a lower comprehensive complication index (4.43 vs. 9.96; p = 0.006). Mean OS (52.3 ± 2.3 vs. 49.9 ± 3.0 months) and DFS (33.9 ± 3.4 vs. 36.5 ± 3.6 months; p = 0.59) were comparable between LLR and OLR, respectively (median not reached). Presence of mixed cholangiocarcinoma/HCC, satellite lesions and AFP level predicted OS and DFS. In addition tumour size was predictive of DFS.ConclusionsIn the studied population minor LLR was associated with shorter hospital stay and fewer complications while offering non-inferior long-term outcomes. A number of predictors for disease free survival have been elucidated that may aid in identifying patients with a high risk of disease recurrence and need for further treatment.     

Outcomes following synchronous liver resection,cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal liver and peritoneal metastases: A bi-institutional study

PurposeSynchronous liver resection, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for colorectal liver (CRLM) and peritoneal metastases (CRPM) has traditionally been contraindicated. However, latest practice promotes specialist, multidisciplinary-led consideration for select patients. This study aimed to evaluate the perioperative and oncological outcomes of synchronous resection in the management of CRLM and CRPM from two tertiary referral centres.MethodThis bi-institutional, retrospective, cohort study included patients undergoing simultaneous liver resection, CRS and HIPEC for metastatic colorectal cancer from 2013 to 2020. Patients treated with ablative liver techniques, staged operative approaches and extra abdominal disease were excluded. Overall survival (OS) and disease-free survival (DFS) rates were assessed. Univariate and multivariate analyses identified variables associated with survival and major morbidity (Clavien-Dindo grade III/IV).ResultsTwenty-three patients were included. The median peritoneal carcinomatosis index (PCI) was 9 (range 0–22). There were two major liver resections and 21 minor resections. CC-0 resections were achieved in all patients. Major morbidity occurred in 7 patients. There were no deaths at 90 days. PCI was independently associated with morbidity (p = 0.04). PCI >10 (p = 0.069), major morbidity (p = 0.083) and presence of KRAS mutation (p = 0.052) approached significance for poor OS. Median follow up was 21 months (4–54 months). Median OS was 37 months, 3-year survival 54%, and median DFS 18 months.ConclusionSynchronous liver resection, cytoreductive surgery and HIPEC is feasible in selected patients with low-volume CRPM and CRLM. Increasing PCI is associated with postoperative major morbidity, and should be considered during operative planning.     

Does the difficulty grade of laparoscopic liver resection for colorectal liver metastases correlate with long-term outcomes?

IntroductionPrognosis of patients with colorectal liver metastases (CRLM) is strongly correlated with the oncological outcome after liver resection. The aim of this study was to analyze the impact of laparoscopic liver resection (LLR) difficulty score (IMM difficulty score) on the oncological results in patients treated for CRLM.MethodsAll patients who underwent LLRs for CRLM from 2000 to 2016 in our department, were retrospectively reviewed. Data regarding difficulty classification, -according to the Institute Mutualiste Montsouris score (IMM)-, recurrence rate, recurrence-free survival (RFS), overall survival (OS) and data regarding margin status were analyzed.ResultsA total of 520 patients were included. Patients were allocated into 3 groups based on IMM difficulty score of the LLR they underwent: there were 227 (43,6%), 84 (16,2%) and 209 (40,2%) patients in groups I, II and III, respectively. The R₁ resection rate in group I, II and III were 8,8% (20/227), 11,9% (10/84) and 12,4% (26/209) respectively (p = 0.841). Three- and 5-year RFS rates were 77% and 73% in group I, 58% and 51% in group II, 61% and 53% in group III, respectively (p = 0.038). Three and 5-year OS rates were 87% and 80% for group I, 77% and 66% for group II, 80% and 69% for group III respectively (p = 0.022).ConclusionThe higher LLR difficulty score correlates with significant morbidity and worse RFS and OS, although the more technically demanding and difficult cases are not associated with increased rates of positive resection margins and recurrence.     

Pure laparoscopic versus open major hepatectomy for hepatocellular carcinoma with liver F4 cirrhosis without routine Pringle maneuver – A propensity analysis in a single center

Background/Aim: Laparoscopic hepatectomy has been gaining popularity but its evidence in major hepatectomy for cirrhotic liver is lacking. We studied the long-term outcomes of the pure laparoscopic approach versus the open approach in major hepatectomy without Pringle maneuver in patients with hepatocellular carcinoma (HCC) and cirrhosis using the propensity score analysis.MethodsWe reviewed patients diagnosed with HCC and cirrhosis who underwent major hepatectomy as primary treatment. The outcomes of patients who received the laparoscopic approach were compared with those of propensity-case-matched patients (ratio, 4:1) who received the open approach. The matching was made on the following factors: tumor size, tumor number, age, sex, hepatitis serology, HCC staging, comorbidity, and liver function.ResultsTwenty-four patients underwent pure laparoscopic major hepatectomy for HCC with cirrhosis. Ninety-six patients who underwent open major hepatectomy were matched by propensity scores. The laparoscopic group had less median blood loss (300 ml vs 645 ml, p = 0.001), shorter median hospital stay (6 days vs 10 days, p = 0.002), and lower rates of overall complication (12.5% vs 39.6%, p = 0.012), pulmonary complication (4.2% vs 25%, p = 0.049) and pleural effusion (p = 0.026). The 1-year, 3-year and 5-year overall survival rates in the laparoscopic group vs the open group were 95.2%, 89.6% and 89.6% vs 87.5%, 72.0% and 62.8% (p = 0.211). Correspondingly, the disease-free survival rates were 77.1%, 71.2% and 71.2% vs 75.8%, 52.7% and 45.5% (p = 0.422).ConclusionsThe two groups had similar long-term survival. The laparoscopic group had favorable short-term outcomes. Laparoscopic major hepatectomy without routine Pringle maneuver for HCC with cirrhosis is a safe treatment option at specialized centers.     

Prognostic relevance of the posterior resection margin for predicting disease free survival in ampullary adenocarcinoma

BackgroundPancreaticoduodenectomy is the only curative treatment option for patients with resectable ampullary adenocarcinoma (AA). Excellent disease free survival (DFS) can be achieved in patients with clear resection margins but it is poorly understood which patients are at increased risk of recurrence and hence would benefit from adjuvant chemotherapy. There is evolving evidence that the anatomical location of incomplete resection margins influences DFS in pancreatic adenocarcinoma. It is unknown if this also pertains to AA and therefore this study aimed to assess individual resection margin status and other predictors of DFS in AA.Material & methodsConsecutive patients undergoing pancreaticoduodenectomy for AA at our institution from 1996 to 2017 were analysed. Pancreas neck, posterior and superior mesenteric vein margins were assessed individually. Cox proportional hazards modelling was used to identify predictors of 5-year DFS. Factors with p < 0.1 on univariate analysis were included for multivariate analysis.ResultsAnalysis of 104 patients revealed median OS and DFS of 56 and 34 months, respectively. Predictors associated with worse DFS on multivariate analysis were T3-stage (HR 3.6, p = 0.048), N1 (HR 2.9, p = 0.01) and N2 -stage (HR 3.6, p = 0.006), R1 status at the posterior margin (HR 3.0, p = 0.009) and a visible mass on CT (HR 2.0, p = 0.039).ConclusionRoutine histopathological assessment of individual resection margins may aid in predicting recurrence of AA. Future studies to assess if routine mesopancreas excision during pancreaticoduodenectomy can reduce the incidence of R1 status at the posterior margin are warranted.     

Therapeutic efficacy of microwave coagulation versus liver resection for hepatocellular carcinoma within the Milan criteria: A propensity score matching analysis

Introduction: This study aimed to compare the therapeutic efficacy of resection (RES) and microwave ablation (MWA) for hepatocellular carcinoma (HCC) within the Milan criteria.Materials and Methods: Between 2011 and 2019, 426 HCC patients within the Milan criteria were treated at our institution (RES: n = 291; MWA: n = 135). We compared overall survival (OS), disease-free survival (DFS), complications, and hospital stay in these patients using propensity score matching (PSM) and determined the prognostic factors using multivariate Cox analysis.Results: Following 1:1 matching using PSM, 121 patients were matched in each group. The 1-, 3-, and 5-year OS rates were 98.3%, 84.7%, and 69.6% for the MWA group and 96.5%, 81.8%, and 78.1% for the RES group (p = 0.667). The corresponding DFS rates for the MWA and RES groups were 81.8%, 54.4%, and 42.3% and 85.4%, 67.8%, and 57.9%, respectively (p = 0.174). The MWA group had less blood loss and shorter hospital stays (both p < 0.001) than the RES group.Conclusion: MWA resulted in survival outcomes that were similar to those of RES for HCC within the Milan criteria. However, it had more favorable hospital stay and blood loss outcomes than RES.     

The importance of surgical resection in the management of rectal sarcoma: A national cancer database analysis of 133 cases

Background and purposeRectal sarcomas (RS) are rare malignant tumors with a very poor prognosis. This study aimed to assess the characteristics, treatment, and outcomes of RS in the United States.MethodsThis study was a retrospective analysis of the National Cancer Database (NCDB) from 2004 to 2019 of patients with a diagnosis of RS. The main outcome measures were overall survival (OS) and its predictors.Results133 RS patients (39.1% female) with a mean age of 65.7 ± 15.6 years were included in the study. Mean tumor size was 6.1 ± 3 cm. The crude OS rate was 22.5% and median survival duration was 10.1 (IQR: 3.2–21) months. Factors associated with an improved OS on were private insurance (HR = 0.23, p = 0.001) and undergoing surgery (HR 0.23, p < 0.001), Factors associated with poor survival were age (HR 1.02, p = 0.005), male sex (HR 2.27, p = 0.001), Charlson score of 3 (HR 5.17, p = 0.003), and positive resection margins (HR: 2.64, p = 0.01). Multivariate Cox regression analysis revealed that male sex (HR 2.16, p = 0.04) and positive resection margins (HR 2.31, p = 0.03) were predictors of poor survival whereas surgery was an independent predictor of improved OS (HR 0.321, p < 0.001)ConclusionsRS is a very rare rectal malignancy with an even poorer prognosis than previously reported. However, undergoing surgery with curative intent while obtaining negative margins may confer better OS.     

5 year oncological outcomes of the HIGHLOW randomized clinical trial

IntroductionThe oncological outcomes of low ligation (LL) compared to high ligation (HL) of the inferior mesenteric artery (IMA) during low-anterior rectal resection (LAR) with total mesorectal excision are still debated. The aim of this study is to report the 5 year oncologic outcomes of patients undergoing laparoscopic LAR with either HL vs. LL of the IMAMaterials and methodsBetween June 2014 and December 2016, patients who underwent elective laparoscopic LAR + TME in 6 Italian non-academic hospitals were randomized to HL or LL of IMA after meeting the inclusion criteria (HighLow trial; ClinicalTrials.gov Identifier NCT02153801). We analyzed the rate of local recurrence, distant metastasis, overall survival, disease-specific survival, and disease-free survival at 5 years of patients previously enrolled.ResultsFive-year follow up data were available for 196 patients. Recurrence happened in 42 (21.4%) of patients. There was no statistically significant difference in the distant recurrence rate (15.8% HL vs. 18.9% LL; P = 0.970) and pelvic recurrence rate (4,9% HL vs 3,2% LL; P = 0.843). No statistically significant difference was found in 5-year OS (p = 0.545), DSS (p = 0.732) or DFS (p = 0.985) between HL and LL. Low vs medium and upper rectum site of tumor, conversion rate, Clavien-Dindo post-operative grade ≥3 complications and tumor stage were found statistically significantly associated to poor oncological outcomes in univariate analysis; in multivariate analysis, however, only conversion rate and stage 3 cancer were found to be independent risk factors for poor DFS at 5 years.ConclusionWe confirmed the results found in the previous 3-year survival analysis, the level of inferior mesenteric artery ligation does not affect OS, DSS and DFS at 5-year follow-up.     

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.     

Efficacy of perioperative chemotherapy in resected colorectal liver metastasis: A systematic review and meta-analysis

BackgroundNearly half of patients with colorectal cancer develop liver metastases. Radical resection of colorectal liver metastases (CRLM) offers the best chance of cure, significantly improving 5-year survival. Recurrence of metastatic disease is common, occurring in 60 % or more of patients. Clinical equipoise exists regarding the role of perioperative chemotherapy in patients with resected CRLM. This investigation sought to clarify the efficacy of perioperative chemotherapy in patients that have undergone curative-intent resection of CRLM.MethodsA systematic review and meta-analysis was completed of randomized controlled trials (RCTs) comparing perioperative chemotherapy to surgery alone in patients with resected CRLM. MEDLINE (Ovid), EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched, as well as abstracts from recent oncology conferences. A meta-analysis was performed pooling the hazard ratios for disease-free survival (DFS) and overall survival (OS), using a random-effects model.ResultsA total of five, phase 3, open-label, RCTs were included resulting in a pooled analysis of 1119 of the total 1146 enrolled patients. 559 patients were randomized to perioperative chemotherapy and 560 to surgery alone. Pooled estimates demonstrated a statistically significant improvement in DFS (HR 0.71, 95 % CI: 0.61–0.82; p < 0.001) but not OS (HR 0.87, 95 % CI: 0.73–1.04; p = 0.136).ConclusionPerioperative chemotherapy in the setting of resected CRLM resulted in an improvement in DFS, however this did not translate into an OS benefit. Poor compliance to post-hepatectomy oxaliplatin-based chemotherapy regimens was identified. Further investigation into the optimal regimen and sequencing of perioperative chemotherapy is justified.     

Comparing surgical and oncologic outcomes between laparoscopic gastrectomy and open gastrectomy in advanced gastric cancer with serosal invasion: A retrospective study with propensity score matching

PurposeLaparoscopic gastrectomy (LG) has gradually increased for treating advanced gastric cancer (AGC). However, there is a lack of evidence on oncologic safety for AGC, especially with serosal invasion. This study evaluates the surgical and oncologic outcomes between laparoscopic and open gastrectomy (OG) for gastric cancer with serosal invasion.MethodsWe retrospectively reviewed 256 patients who underwent OG and 147 patients who underwent LG for gastric cancer with serosal invasion between August 2005 and December 2017. Finally, 124 patients in the LG group and 124 in the OG group were enrolled according to one-to-one propensity score matching (PSM) analysis. We evaluated surgical and oncological outcomes, including overall survival (OS) and recurrence-free survival (RFS).ResultsThere were no statistical differences in hospital stay and major complications between the two groups. The retrieved lymph nodes of the LG group were similar to those of OG (40 ± 16.23 vs. 38 ± 14.42, p = 0.306), and it showed a similar operation time compared with the other (164 ± 43.86 vs. 156 ± 37.66, p = 0.063). There was no statistical difference in OS (p = 0.761) and RFS (p = 0.121) for survival analysis between the two groups.ConclusionLG for gastric cancer with serosal invasion is feasible and could be considered as a standard treatment.     

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).     

Effect of age on the short- and long-term outcomes of patients undergoing curative liver resection for HCC

BackgroundFew studies have evaluated the outcomes of curative liver resection (LR) in octogenarian patients, analysed cancer-specific survival (CSS) with HCC-related death or explored the age-varying effect of HCC-related death in elderly patients undergoing LR. We aim to determine the effect of age on the short and long-term outcomes of LR for HCC.MethodologyBetween 2000 and 2018, 1,092 patients with primary HCC who underwent LR with curative intent were retrospectively reviewed. The log-rank test and Gray's test were used to assess the equality of survivor functions and competing risk-adjusted cumulative incidence functions between patients in the three age categories respectively. Regression adjustment was used to control for confounding bias via a Principal Component Analysis. Quantile, Firth logistic, Cox, and Fine-Gray competing risk regression were used to analyse continuous, binary, time-to-event, and cause-specific survival respectively. Restricted cubic splines were used to illustrate the dose-effect relationship between age and patient outcomes.ResultsThe study comprised of 764 young patients (<70 years), 278 septuagenarians (70–79 years old) and 50 octogenarians (≥80 years). Compared to young patients, octogenarians had significantly lower 5-year OS(62.1% vs 37.7%, p < 0.001). However, there was no significant difference in 1-year RFS(73.1% vs 67.0%, p = 0.774) or 5-year CSS (5.4% vs 15.2%, p = 0.674). Every 10-year increase in age was significantly associated with an increase length of stay (p < 0.001), postoperative complications (p = 0.004) and poorer OS(p = 0.018) but not significantly associated with major complications (p = 0.279), CSS(p = 0.338) or RFS(p = 0.941).ConclusionAge by itself was associated with OS after LR for HCC but was not a significant risk factor for HCC-related death.     

Comparative study on the oncological prognosis of laparoscopy and laparotomy for stage IIA1 cervical squamous cell carcinoma

ObjectiveTo compare the 5-year overall survival (OS) and disease-free survival (DFS) rate of laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH) for stage IIA1 cervical squamous cell carcinoma.MethodsBased on a large database containing information on the clinical diagnosis and treatment of cervical cancer in China, the oncological outcomes of the two surgical approaches for stage IIA1 cervical squamous cell carcinoma were compared after 1:2 propensity score matching (PSM).ResultsAfter 1:2 propensity score matching (PSM), 510 patients were included in the LRH group, and 999 patients were included in the ARH group. LRH showed a similar 5-year OS but a lower DFS rate (81.3% vs. 87.4%, P = 0.018) than ARH. In the multivariate analysis, LRH was identified as an independent risk factor for worse 5-year DFS (HR = 1.569, 95% CI: 1.131–2.176, P = 0.007). Among patients with a tumour size <2 cm, the LRH and ARH groups showed similar OS and DFS rates after 1:2 PSM, and multivariate analysis showed that the surgical approach was not an independent risk factor affecting the OS or DFS rate. Among patients with a tumour size ≥2 cm and <4 cm, there was no difference in OS between the LRH and ARH groups after matching, but the DFS in the LRH group was significantly lower than that in the ARH group (81.1% vs 86.2%, P = 0.034). In the multivariate analysis, the laparoscopic approach was not associated with OS but was independently associated with worse DFS (HR = 1.546, 95% CI: 1.094–2.185, P = 0.014).ConclusionsLRH was associated with poorer 5-year DFS than ARH in patients with stage IIA1 cervical squamous cell carcinoma. However, LRH showed 5-year OS and DFS rates similar to those of ARH among patients with a tumour size <2 cm. For patients with a tumour size ≥2 cm and <4 cm, LRH showed a lower DFS rate than ARH.     

Laparoscopic approach for T4 colon cancer can be associated with poor prognosis in right-sided T4b tumours

IntroductionAlthough recent studies have demonstrated the safety of laparoscopic surgery in T4 colon cancer, some patients could have poor prognosis. In this study, we aimed to analyse the risk factors affecting oncologic outcome of laparoscopic surgery.Materials and methodsAmong the 1033 T4 colon cancer patients collected from a multicentre database (2004–2017), 584 patients (458 T4a and 126 T4b) underwent laparoscopic approach for radical surgery. Risk factors associated with 3-year disease-free survival (DFS) and overall survival (OS) were evaluated through multivariate analysis. In addition, subgroups were classified using a combination of risk factors, and the survival rate was evaluated.ResultsDuring this period, 188 (32.2%) had recurrence, and 151 (25.9%) died. In the multivariate analysis for oncologic outcome, elevated carcinoembryonic antigen level (hazard ratio [HR] 1.37) and absence of adjuvant chemotherapy (HR 1.60) were associated with poor DFS. T4b (HR 1.56, 1.46), right-sided location (HR 1.52, 1.42), and open conversion (HR 2.70, 2.12) were independently associated with both poor DFS and OS. When four subgroups were analysed through the combination of tumour location and T stage, the DFS and OS rates were significantly lower in patients with right-sided T4b cancer than in other groups (log-rank p < 0.001).ConclusionRight-sided T4b colon cancer for laparoscopic surgery may lead to poor oncologic outcome. This approach could be a caution in suspected cases preoperatively.     

Preoperative C-reactive protein-to-albumin ratio and clinical outcomes after resection of colorectal liver metastases

PurposeAccumulating evidence suggests that the inflammatory tumor microenvironment can potentiate tumor progression and metastasis. The C-reactive protein-to-albumin ratio (CAR) is a novel inflammation-based prognostic score. This study was performed to examine the associations of the preoperative CAR with clinical outcomes in patients with colorectal liver metastases (CRLM) after curative resection.MethodsWe retrospectively assessed the preoperative CAR in 184 patients who underwent curative resection for CRLM from November 2001 to January 2018 at Kumamoto University (Kumamoto, Japan). The optimal cutoff level of the preoperative CAR was determined by survival classification and regression tree (CART) analysis. We compared clinicopathological factors and prognoses between the high-CAR and low-CAR groups. A Cox proportional hazards model was used to calculate hazard ratios (HRs), controlling for potential confounders.ResultsA higher preoperative CAR was associated with worse overall survival (OS) (p < 0.0001) and recurrence-free survival (RFS) (p = 0.003). Applying survival CART analysis, the high-CAR group comprised 33 patients (17.9%). In the multivariate analyses, a high CAR was independently associated with shorter OS (HR, 2.82; 95% confidence interval, 1.63–4.72; p = 0.0004) and RFS (HR, 1.62; 95% confidence interval, 1.02–2.49; p = 0.040). A high CAR was associated with a large tumor size, high serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels, high intraoperative blood loss, and more postoperative complications.ConclusionA high preoperative CAR is associated with shorter OS and RFS and might serve as a prognostic marker for patients with CRLM after curative resection.