Laparoscopic liver resection for hepatocellular carcinoma: ten-year experience in a single center.

HYPOTHESIS: Laparoscopic hepatectomy and open hepatectomy for hepatocellular carcinoma (HCC) have the same surgical outcome. DESIGN: Nonrandomized comparative study. SETTING: Tertiary referral center. PATIENTS: Twenty-five consecutive patients with HCC undergoing laparoscopic hepatectomy from January 1, 1998, through December 31, 2007, and a retrospective control group of 33 patients who underwent open hepatectomy for HCC during the same period. The 2 groups were matched in terms of demographic data, tumor size, and severity of cirrhosis. INTERVENTIONS: Laparoscopic hepatectomy. MAIN OUTCOME MEASURES: Surgical morbidity rate, mortality rate, and survival. RESULTS: One patient in the laparoscopic group underwent conversion to an open approach. The median operating time and blood loss were 150 minutes and 200 mL, respectively. The resections were R0 in 22 patients (88%) and R1 in 3 (12%). The hospital mortality and morbidity rates were 0% and 16% (4 patients), respectively. The 3-year overall and disease-free survival rates were 60% and 52%, respectively. There was no difference in surgical morbidity rate, hospital mortality rate, and midterm survival results between the 2 groups. The laparoscopic approach resulted in a shorter hospital stay. CONCLUSIONS: Laparoscopic hepatectomy for HCC is feasible and safe in selected patients. Midterm survival is also favorable. The laparoscopic approach has the benefit of a shorter hospital stay. However, the procedure should be performed by a surgical team expert in hepatobiliary and laparoscopic surgery in properly selected patients.

Cytoreductive surgery in multidisciplinary treatment of advanced hepatocellular carcinoma.

BACKGROUND: Cytoreductive surgery (debulking surgery) as a multidisciplinary treatment approach for inoperable advanced hepatocellular carcinoma has been shown to prolong survival and provide symptomatic relief for good surgical risks patients in non-randomized studies before. METHODS: A non-randomized comparative study was performed in a tertiary referral centre between January 2001 and December 2006. The outcome of a consecutive series of patients with inoperable advanced hepatocellular carcinoma who received cytoreductive surgery was compared with a control group of patients who received palliative treatment without surgery. Two techniques of cytoreductive surgery were used: (i) partial hepatectomy for the main tumour plus intraoperative local ablative therapy for the smaller tumour nodules in the liver remnant; and (ii) partial hepatectomy for the main tumour plus postoperative transarterial chemoembolization. RESULTS: The overall survival of cytoreductive surgery group (n = 18) was significantly better than that of the palliative treatment group (n = 15) (3-year overall survival, 54% vs 22%; median survival, 18 vs 11 months) (P =0.038). In the cytoreductive surgery group, there was no operative mortality. Postoperative morbidity rate was 16.7%. The mean hospital stay was 8 days. CONCLUSION: Cytoreductive treatment strategy for advanced hepatocellular carcinoma can be considered as one of the options in selected patients with low operative risks and reasonable liver function. Further prospective randomized trials are required to validate this aggressive surgical approach.

The evolving influence of laparoscopy and laparoscopic ultrasonography on patients with hepatocellular carcinoma.

BACKGROUND: With the recent introduction of laparoscopic partial hepatectomy and laparoscopic/open radiofrequency ablation for hepatocellular carcinoma (HCC), the role of preoperative laparoscopic staging may be expanded. The objective of this study was to determine the role of preoperative laparoscopy and laparoscopic ultrasonography (USG) in patients with HCC. METHODS: From January 2001 to April 2007, a cohort of 122 consecutive patients with a diagnosis of potentially resectable HCC underwent staging laparoscopy with laparoscopic USG before performing a major laparotomy in a tertiary referral center. The patients' data were collected prospectively. We have retrospectively analyzed the effect of implementation of this staging technique in our center. RESULTS: Preoperative laparoscopy and laparoscopic USG was successful in 119 patients (97.5%). Forty-four patients were found to be unresectable after laparoscopic staging, whereas 2 patients were found to be unresectable after exploratory laparotomy. The total number of patients who underwent curative liver resection was 73 (laparoscopic partial hepatectomy, 22 patients; open partial hepatectomy, 51 patients). The median hospital stay of the laparoscopic liver resection group was significantly shorter than that of the open resection group (8 vs 13 d; P = .002). Intraoperative treatment for patients with unresectable HCC, including local ablative therapy, or combined liver resection and local ablative therapy, was performed in 27 of 45 inoperable patients (60%) (laparoscopic approach, 8 patients; open approach, 19 patients). The median hospital stay of the laparoscopic treatment group was significantly shorter than for the open treatment group for patients with unresectable HCC (5 vs 7 d; P = .003). In this study, a laparoscopic treatment approach for HCC was performed in 25.2% of the study population. CONCLUSIONS: Laparoscopy and laparoscopic USG have a significant effect both on identifying surgically untreatable disease and in selecting the optimal treatment strategy. Some patients will benefit from a laparoscopic therapy approach. Therefore, it argues for more widespread use in laparoscopic staging procedures for patients with potentially resectable HCC.

Laparoscopic treatment of recurrent pyogenic cholangitis.

BACKGROUND/PURPOSE: We reviewed the selective use of hand-assisted laparoscopic segmentectomy (HALS) and laparoscopic choledochoduodenostomy (LCD) in the management of recurrent pyogenic cholangitis (RPC). METHODS: We carried out a retrospective review of a prospectively maintained database of laparoscopic treatment of RPC during the period 1995 to 2004. The perioperative data were analyzed. RESULTS: There were 33 laparoscopic procedures performed in 30 patients with RPC during the period 1995--2004. There were 23 female and 7 male patients, with a mean age of 63.2+/-14.9 years (range, 29--92 years). All these patients had a history of repeated attacks of cholangitis, and multiple sessions of endoscopic lithotripsy or operative retrieval had previously been attempted. Of these 33 procedures, there were 23 LCDs and 10 HALS. Three patients underwent simultaneous LCD and HALS in the same operation. The mean operative time was 172+/-63.5 min (range, 75--290 min) and there were three open conversions (10%), due to (1) intraoperative bleeding from the left hepatic vein, (2) lost broken tip of ultrasonic dissector, and (3) significant bleeding during choledochotomy, respectively. Average hospital stay was 11.4+/-11.1 days (range, 5--60 days). Eight complications (26.6%) were encountered, which included four bile leaks, three wound infections, and one intraabdominal collection. Complete stone clearance was achieved in all but 1 patient (rate, 96.6%), in whom the residual stones were extracted through a postoperative combined endoscopic and percutaneous approach. Long-term results were satisfactory, and only one stone recurrence was detected, upon a mean follow-up of 34.7 months (range, 1--107 months). CONCLUSIONS: Both LCD and HALS are safe, feasible, and effective treatments for patients with RPC.

Pseudo-Bouveret's syndrome.

We report a patient with gastric outlet obstruction due to gallstone, with clinical and imaging features mimicking Bouveret's syndrome. However, the obstruction was simply due to extrinsic compression by a gallstone without cholecystoduodenal fistula formation. Laparoscopic cholecystectomy cured the patient.