Laparoscopic vs Open Hepatectomy: Similar Short-term Results

Fran Lowry

August 04, 2014

A study comparing laparoscopic vs open hepatectomy for the management of benign and malignant liver disease shows similar outcomes for both procedures in the short-term (ie, 30 days). But whether these results hold true for the long-term, which would be especially important for malignant disease, remains to be discovered.

The study, led by Cara Franken, MD, and colleagues from the Department of Surgery, Kaiser Permanente Los Angeles Medical Center, California, was published online July 30 in JAMA Surgery.

"In any cancer series...the real proof is in long-term outcomes, and I am hopeful that long-term results will be reported later," writes Thomas R. Biehl, MD, from the Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, in an invited commentary.

"We don't have great data on the oncologic outcomes of laparoscopic liver resection," the study's senior author, L. Andrew DiFronzo, MD, chief, Department of General Surgery at Kaiser Permanente Los Angeles Medical Center, told Medscape Medical News.

Dr. L. Andrew DiFronzo

"Although short-term outcomes are important, the long-term results are more crucial," Dr. DiFronzo noted.

"Even if short-term results are improved by a laparoscopic approach, that benefit will be outweighed if there are worse long-term cancer outcomes. Future studies are needed to determine oncologic equivalence to open hepatectomy," he said.

Complications Not Decreased by Laparoscopic Approach

Dr. DiFronzo and colleagues decided to compare the 2 procedures after anecdotally observing that patients undergoing laparoscopic hepatectomy continued to have significant pulmonary complications.

"I was surprised to find that some complications were not decreased by the laparoscopic approach, primarily the pulmonary complications. I would have expected pulmonary complications to be less common and less severe as a result of smaller incisions, and therefore there would be less pain, splinting, atelectasis, and so on," he said.

"Prior studies have suggested that the laparoscopic approach to liver resection improves outcomes, and does so significantly. Our study calls that into question. We found that the advantages of laparoscopic hepatectomy, if any, are modest, but our results, like those of previous studies, are confounded by selection bias," he said.

The Kaiser Permanente team retrospectively reviewed 104 patients undergoing partial hepatic resection at their institution from April 1, 2004, to March 31, 2013.

Half (52) of the patients underwent laparoscopic hepatectomy, and 52 had open hepatectomy. The patients were matched for age, sex, cirrhosis (which was present in 17 [33%] patients in each group), extent of resection, and diagnosis.

The most common indication for resection was hepatocellular carcinoma, accounting for 54% in each group. Resection for colorectal metastasis was done in 10% of the laparoscopic group and in 23% of the open group. All other resections for malignant disease, including metastatic adenosquamous carcinoma, gallbladder adenocarcinoma, and cholangiocarcinoma, represented 12% of the laparoscopic group and 8% of the open group (P = .74).

Benign indications, including hepatolithiasis, hepatic adenoma, biliary cystadenoma, cyst, focal nodular hyperplasia, and hemangioma, represented 25% of the laparoscopic cases and 15% of the open group.

Laparoscopic hepatectomy was offered selectively to those patients with 1 or 2 masses, masses away from major vessels and portal structures, and masses located mostly in segments 2 to 3, 4b, 5, or 6.

The main outcomes were 30-day morbidity and mortality rates.

The 30-day outcomes were similar in both groups. However, laparoscopic hepatectomy was associated with lower intraoperative blood loss. The authors state that the clinical significance of this finding is uncertain, given the lack of difference in perioperative transfusion or morbidity rates.

Table. Short-term Outcomes in Laparoscopic vs Open Hepatectomy

Outcome Laparoscopic Group Open Group P-Value
Operating time, mean (range), minutes 219 (84 - 449) 198 (107 - 347) .16
Estimated blood loss, mean (range), mL 237 (10 - 1200) 387 (25 - 3000) .049
Perioperative blood transfusion 1(2%) 5 (10%) .20
Pulmonary complications 11(21%) 9 (17%) .80
Cardiac complications 3 (6%) 3 (6%) >.99
Bile leakage 0 2 (4%) .49
Surgical site infection 1 (2%) 5 (10%) .21
30-day mortality 1 (2%) 2 (4%) >.99
Length of hospital stay, mean (range), days 5 (1 - 17) 6 (3 - 23) .13
Readmission rate 4 (8%) 5 (10%) .70

In addition, there was no difference in margin status between the 2 groups.

Selection Bias Difficult to Overcome

"We made an effort to reduce selection bias by trying to match patients very carefully, but in the end, this was still challenging," Dr. DiFronzo said. "So our study and prior studies are effectively comparing 'apples to oranges.' "

Dr. DiFronzo also noted that the study did not address certain outcomes that might be improved by a laparoscopic approach, such as cosmesis, incidence of incisional hernia, long-term incidence of bowel obstruction, and return to normal activities.

Dr. DiFronzo added that at this time, it is difficult to state with any certainty just which patient will benefit from laparoscopic hepatectomy.

"I don't think we can confidently say which patients benefit from a laparoscopic approach. I generally will consider laparoscopic hepatectomy in patients with single tumors in favorable locations of the liver. It's really up to the surgeon to decide who is or is not a good candidate. I think an experienced liver surgeon will have both approaches available in his or her armamentarium and should know how to select the right operation for the right patient, and also that it is entirely reasonable for a patient to inquire with their surgeon about whether or not a laparoscopic approach would be appropriate for their specific case."

He added that he hopes the study will not only foster further study but will encourage more critical application of the laparoscopic approach to liver resection.

A Commendable Effort

In his commentary, Dr. Biehl commends Dr. DiFronzo and his team "for an outstanding attempt" to eliminate selection bias in their review.

Although the patients were matched "almost as if they had been prospectively randomized," differences among them are notable, including the absence of laparoscopic hepatic resections of segments 1 and 4 and a failure to study similar open resections.

This shows that patients were chosen for laparoscopic resection on the basis of the expectation of the surgeon that the outcome was going to be good, Dr. Biehl writes.

"We all do this every day. It is the mark of a good surgeon, not only technically, but judgmentally. In fact, most would argue that good preoperative judgment is the key to good outcomes despite technical expertise, but preoperative judgment cannot really be accounted for in this retrospective study," he writes.

The short-term outcomes clearly are good, Dr. Biehl emphasizes, adding that he hopes the results of future long-term studies will be "as good as or even better than those of open hepatectomy. If these long-term outcomes are improved, the improvement will be not only because the procedures are laparoscopic but also because they are performed well, by a good surgeon who knows when to operate, when not to, and how to do so."

Dr. Franken, Dr. DiFronzo, and Dr. Biehl have disclosed no relevant financial relationships.

JAMA Surg. Published online July 30, 2014. Article abstract, Commentary extract

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